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TYPHOID FEVER EPIDEMIC 

AT PALO ALTO, CALIFORNIA 



J. C. L. FISH 



TYPHOID FEVER EPIDEMIC 

AT PALO ALTO, CALIFORNIA 

A REPORT MADE TO 
THE PALO ALTO BQARD OF HEALTH 

By J. C. L. FISH, Assoc. M. Am. Soc. C. E. 

President of the Board 



Including 
An Analysis of Reported Cases 

by 

CLELIA DUEL MOSHER, A.M., M. D. 

and 

Source of Infection of the Milk Supply 
by 

WILLIAM FREEMAN SNOW, A.M., M. D. 



1905 

THE BOARD OF HEALTH 
PALO ALTO, CALIFORNIA, U. S. A. 



LIBRARY of CONGRESS 
Two CoDies Received 



FEB ,18 1906 




COPYRIGHT, 1905, 
BY 

JOHN CHARLES LOUNSBURY FISH 



Presented to jhe Palo Alto Board of Health, May 29, 1905 

Published as a public document by authorization of the Board of 
Trustees of Palo Alto, given June 1, 1905 



TABLE OF CONTENTS 



PAGE 



Part I. Sanitary Conditions Before Epidemic. 

Topography and Geology 7 

Growth of Community; Sanitary Arrangements S 

Sanitary Measures in Palo Alto previous to Epidemic 9 

History of Typhoid Fever previous to Epidemic 9 

Part II. The Epidemic. 

The Epidemic. 9 

Summary of Statistics ; 10 

Sanitary Measures in Palo Alto during Epidemic 10 

Part III. Sanitary Conditions Sincr Epidemic. 

History of Typhoid Fever since Epidemic 12 

Floating Population 13 

Character of Population favors Sanitary Progress 13 

Sanitary Measures in Palo Alto since Epiderhic 14 

Sanitary Measures at Stanford University since Epidemic 16 

Part IV. Opinion and Comment. 

Cause of the Epidemic 16 

Secondary Infection 18 

Safety of Public Health at Palo Alto and Stanford University ... 18 

Part V. Analysis of Cases (Contributed by Dr. AIosher). 

Number of Cases, Age, Sex 19 

Symptoms 23 

Complications.. 27 

Secondary Infection -. 35 

Part VI. Source of Infection of the P. Milk (Contributed by Dr. Snow.) 

Scheme of Investigation 37 

Presentation of Data 39 

Recapitulation and Conclusion 47 

Part VII. Appendices. 

A. — Minutes of Meetings of Palo Alto Board oE Health 50 

B. — Typhoid Fever Report Blank 51 

C. — Report on Inspection of P. Dairy 52 

D. — Report on Inspection of N. Dairy 53 

E. — L.'s Records 55 

F. — Details of Cases (By Dr. Sn w) 56 

G. — Details of Groups of Cases (By Dr. Snow) 57 

H. — Reorganization of the P. Dairy 58 

I. — Sanitary Science, Physicians and the People 59 

Concerning Quarantine 59 

Supervision of Milk Supply . 61 



ILLUSTRATIONS 



PAGE PAGE 

7 Fig. 6. 34 

facing 9 Fig. 7 facing 17 

.... 45 Fig. 8 ,38 

.... 20 Fig. 9 52 

face 20 Fig. 10 53 



THE TYPHOID FEVER EPIDEMIC AT PALO ALTO, 

CALIFORNIA 



PART I. SANITARY CONDITIONS BEFORE THE EPIDEMIC. 

The epidemic occurred at Stanford University as well as at 
Palo Alto, and for this reason the general sanitary conditions 
of both places are here given. 

Topography and Geology. — Palo Alto, 34 miles southeast 
of San Francisco, and 3 miles west of the Bay of San Francisco 




FiG.l- PALO ALTO and VICINITY 



8 



TYPHOID FEVER AT PALO ALTO, CAL. 



(Fie. i), is built on that portion of the floor of Santa Clara 
Valley which lies between the Bay of San Francisco and the 
Coast Range. Stanford University lies contiguous to 

the foothills of the Coast Range, a mile to the southwest of 
Palo Alto, with which it has no political connection. The 
valley floor has a continuous fall from an elevation of lOO feet 
at the University, through Palo Alto (whose elevation is about 
50 feet) to the Bay. The soil is in some parts gravel and in 
others loam or adobe. 

Growth of Community: Sanitary Arrangements. — For a 

number of years preceding 1891 the site of Palo Alto was a 
wheat fl.eld. Palo Alto was incorporated as a town of the 
sixth class on April 16, 1894. Before 1897 the water supply of 
the town cam.e from private deep wells, pumped by wind and 
gas motors. The tOAvn built a complete system of water 
supply in 1897, drawing water from flowing wells ranging in 
depth from 150 to 300 feet. Before 1899 nearly all the build- 
ings Ml the town were furnished with modern plumbing, and 
the house sewers emptied into cesspools. There were few 
privies. A system of sewers covering the occupied 

streets Avas constructed in 1899 ; and citizens were directed by 
ordinance to connect with the town sewer, to fill cesspools 
and privy vaults and remove privies. The sewerage system 
of the town has been extended as rapidly as required by the 
growth of the town. 

The University (Fig. 2), built on unoccupied ranch land, 
was opened in 1891. The drinking water was until 1900 taken 
from a deep well and distributed to houses by wagon, and the 
water for other purposes was taken from Searsville Lake, a 
reservoir located above the University in the foothills (Fig. i). 
Since 1900 the whole domestic water supply for the Univer- 
sity has been pumped from deep wells through a complete 
system of distributing ])ipes. All buildings were supplied 
with modern j)lum])ing, and connected with a complete sew- 
erage system, the outlet oi which was at the sewage farm lo- 
cated at the south corner of the Embarcadero Road and S. P. 
R. R. till 1899; and after that, at the Bay. 



LELAND STANFOR 
JUNIOR 
UNIVERSITY ^ 

SCALE 

I ' )4 Illli — — ' 



TYPHOID FEVER AT PAI.O ALTO, CAL. 



9 



Sanitary Measures in Palo Alto Previous to Epidemic. — On 

October 6, 1902, the Palo Alto Board of Health asked the 
Town Trustees to appoint an expert dairyman as milk in- 
spector. On December i, following, the Trustees having 
taken no action in this matter, the Board asked the Trustees at 
what time they expected to act. Some time in January, 1903, 
it was indirectly learned that the Trustees, because of a lack 
of funds, intended to take no action in the matter. (See Ap- 
pendix A.) The Board after making a study of milk ordi- 
nances of several American towns and cities, at once set about 
drafting a milk ordinance. On February 16, 1903, the 

Board engaged an inspector to make a house-to-house can- 
vass of the town to locate any insanitary conditions, especially 
privies and unfilled cesspools. This inspection, begun on 
February 21, resulted in the arrest of upwards of fifty prop- 
erty owners who were responsible for the existence of privies 
and cesspools contrary to ordinance. Practically all privies 
and cesspools were promptly efifaced. 

History of Typhoid Before Epidemic. — The writer, who has 
lived in Palo Alto since 1894, does not remember the existence 
of any typhoid fever in Palo Alto between 1894 and 1903, 
though there may have been one or more cases. The secre- 
tary of the Board states that no cases of typhoid were reported 
to the Board during the two years preceding this epidemic. 
Before 1901, reports of cases of contagious disease were not 
preserved. 

At the University between 1898 and 1903 there were, so. far 
as is known, four cases of typhoid fever. Three of these 
occurred at the opening of the fall semester ; the patients were 
students who had just returned from vacations. The fourth 
case occurred in the spring of 1899 and the cause of infec- 
tion is unknown. In the last case the sufferer was a student 
boarding himself and using water from a source used by no 
other student. 

PART ir. THE EPIDEMIC. 

The Epidemic. — The rise, progress, and decline of the epi- 
demic are clearly shown in Chart A (Fig. 5). The ist case of 



10 



TYPHOID FE\"ER AT PALO ALTO, CAL. 



typhoid occurred December lo, 1902 ; the 2d^ case on January 
15. The 3d case developed February 17. By April ist 27 
cases had developed, and 16^ of these had called the doctor 
(Chart B, Fig. 5). The number of cases developing each day 
increased from two on ]\Iarch 31st to 18 on April 15th, and 
then rapidly declined to April 27th on which date there was 
one case. The last 16 cases developed during the month end- 
ing yia.y 28. 

The epidemic w^as caused by P. milk (see p. 16). 



Summary of Statistics. 

No. Percent. 

Number of known cases within the corporate limits of 

Palo Alto 176 75 

Number of known cases outside of the corporate limits of 

Palo Alto 60 • 25 

Number of known cases in the Palo Alto epidemic 236 100 

Number of deaths in the epidemic 12 

Ratio between deaths and cases (per cent.) 5 

Number of users of milk in Palo Alto and on the Univer- 
sity campus (see p. 39) 900 

Ratio between cases and users of P. milk (percent) 26 

Population of Palo Alto and University campus (estimated) 3.500 
Ratio between number of cases and population (percent) ... 6.7 
Cases reported to the Palo Alto Board of Health on 
special blanks (Appendix E) : 

In Palo Alto 174 

Outside of Palo Alto 34 

Total cases thus reported 208 

Ratio between number of cases thus reported and number 

of cases in epidemic (per cent.) 88 

Sanitary Measures in Palo Alto During the Epidemic. — 



At a special meeting of the Board of Health^ held in the even- 
ing of March 31st, 1903, it was stated by the secretary that 
there had been reported 4 cases of typhoid fever in Palo Alto 
and that the only article of food common to the four patients 
had been milk supplied by milkman L. It was further stated 



' The Board of Health was not notified of these two cases until some time in May. 

* Of these 16 cases the doctors had on the evening of March .31 reported onlj'^ 4. 

» The Board of Health of Palo Alto had, on January 1st, 190.3, been reduced by 
withdrawals from 5 to 3 members. The three remaining members — Dr. F. Heyden 
Moss. h<--alth officer; J. W. Roller, Fccretary; J. C. L. Fish, president — carried on the 
Board work from this date until June 1st. 1903. No salary attaches to the office of 
member of the Palo Alto Board of Health. 



TYPHOID FEVER AT PALO ALTO, CAL. 



II 



that a suspected case of typhoid had been reported by the at- 
tending physician and that the patient in this case had used 
milk from his family cow only. Notwithstanding the 
report of this suspected case, the Board decided that their 
first investigation should be planned on the theory that the 
milk supplied by L. was infected. In pursuance of this plan, 
inquiry was made as to the source of L.'s milk supply and it 
was learned that L. got his milk from P., a dairyman occupying 
the F. ranch, on Los Trancos creek (Fig. i). Accord- 
ingly on the following morning (April i), the president and 
secretary of the Board inspected the P. dairy, took a sample 
of water supply used in washing the cans and cooling the milk, 
and a sample of milk which was waiting for delivery to milk- 
man L. A report (Appendix C) on this inspection was made 
to the Board of Health at a meeting held in the evening of the 
same day. At this meeting the Board directed that the 

P. dairy house and utensils be disinfected, present water sup- 
ply cut off and water be taken from spring A^ (Fig. 9, and Ap- 
pendix H) ; and that the washing of cans and handling of milk 
at the dairy be done under the supervision of the secretary of 
the Board, pending the report on the milk and water samples. 

The town water supply had already been submitted to 
bacteriological examination and found to be wholesome. At 
this time it was ascertained that the vegetable supplies of the 
families of the patients came from widely different sources, 
and further, that only one of the patients had eaten any un- 
cooked food other than milk. None had eaten raw oysters or 
clams. 

On April 8, a bacteriologist of San Francisco, to whom 
the P. water and milk samples had been sent for examination, 
reported that the water and milk contained large numbers of 
bacillus coli communis. The Board on this date ordered L. 
to sell no more milk in the town, and ordered the disinfec- 
tion of all the milk utensils of L. and of L.'s customers under 
the direction of the secretary. 

On April 7 the president and secretary of the Board in- 



^ Marked "Hill Spring" in Fig. 3. 



12 



TYPHOID FEVER AT PALO ALTO, CAL. 



spected the N. Dairy (Figs, i and lo), and in the evening 
presented their report (see Appendix D) to the Board. On 
April 8 the Board ordered N. to sell no more milk in Palo 
Alto. (On April i8 N. was arrested and fined for attempting 
to sell the milk in the tow^n.) 

During the following two months the president and secre- 
tary of the Board, consulting daily with the health officer, 
devoted the greater part of the time to the betterment of the 
sanitary conditions of the town. All the dairies supplying 
Palo Alto with milk were inspected and samples of milk and 
dairy water-supplies were given bacteriological examination. 
Though none of these samples were condemned, it was found 
needful to order in every dairy changes in many details to 
protect the milk and the sources of water from possible fu- 
ture contamination. Rules were made and carried out for the 
construction, use and destruction of the temporary privies 
erected for the use of workmen on premises where building 
was in progress. 

A milk ordinance^ was drafted by the Board of Health, and 
passed June 6 by the Town Trustees. 

PART III. SANITARY CONDITIONS SINCE THE EPIDEMIC. 

History of Typhoid Since Epidemic. — There have occurred 
in Palo Alto since the epidemic, 8 cases of typhoid fever, scat- 
tered over the interval between November ii, 1903, and Oc- 
tober 25, 1904. It is certain that 4 of these patients were in- 
fected while outside of the territory of Palo Alto and the Uni- 
versity. In the other four cases, the probable source of in- 
fection could not be fixed, notwithstanding thorough investi- 
gation in cadi case. 

At tlic I 'ni\ cr^it y- there have been 5 cases since the epi- 
demic. J'^irst case — .April, 1904; manager of college paper, 

' In fixing some of tlie details of tlu- onlinrmcc , in tin iiisiu ction of three of the 
dairies, and on questions of Rcncr;i] polity in connection wiih the projwsed supervision 
of the milk supply, the P>oar(l IkkI tli" -rKnnt.i.iic tif the training and experience of 
Mr. Roger Roberts, of Palo Alio, !;r.iiln;it( (.f ilu- College of Agriculture of Cornell 
University, for three years oHici.il milk ti ^ci in Xcw York State for the A. R. O., 
and later Professor of Dairy 1 1 nsh.mdi y in National Tarni Scliool, Doylestown, Pa., 
who freely gave the time he could take from business. 

- Statistics stif)plicd by Dr. Snow. 



TYPHOID FEVER AT PALO ALTO, CAL. 



13 



frequently in San Francisco, where he ate raw oysters. Sec- 
ond and third — both in one family; taken ill immediately on 
returning from visit to distant point. Fourth case — in De- 
cember, 1904; attributed, by process of elimination, to raw- 
clams collected near the mouth of the sewer of the Mayfield 
brewery, and in direct line of tidal current sweeping past the 
outlets of the Palo Alto and University sewer systems. 
Fifth. — March, 1905 ; patient had taken meals in San Francisco 
restaurants. 

Floating Population. — A floating population of¥ers greater 
opportunity for the importation of infectious and contagious 
diseases than a stationary one. Several men who 

work daily in offices in San Francisco return each evening to 
their homes in Palo Alto. The people of the community go 
much to San Francisco for business, shopping and entertain- 
ment. In September some 1,300 students from all parts come 
to the University, and of these about 400 board and lodge in 
Palo Alto, while more than 700 live on the University campus. 
About 1,000 students go to their homes for Christmas and 
Easter vacations. About 100 students residing in San Fran- 
cisco, San Jose, and intermediate points, travel daily between 
the University and their homes. Many Palo Alto families 
spend the summers at the seaside or in the mountains, rent- 
ing their homes to families from San Francisco or the interior 
valleys of the state. Finally, there are during the year many 
hundreds of tourists visiting us. If any one of these 

persons becomes infected with the germs of a contagious 
disease just before coming or returning to Palo Alto, that per- 
son will become a case of contagious disease here in spite of 
all sanitary precautions. To prevent the spread of contagious 
disease thus brought to us the Board of Health must be on the 
alert, and have the cheerful co-oneration of the physicians and 
the people. 

Character of Population Favors Sanitary Progress. — The 

people of Palo Alto live on a comparatively high sanitary 
plane ; there is no ''foreign quarter/' no "poor quarter," no 
tenement district. The population is made up of those who 



14 



TYPHOID FEVER AT PALO ALTO, CAL. 



have come to take advantage of the educational facilities of 
the town and the University ; and those who have come to 
supply the material needs of the foregoing. Because of the 
generally high intelligence and progressive spirit of the people, 
it is comparatively easy to gain their co-operation in all things 
tending to improve the sanitary conditions ; and the Board of 
Trustees of Palo Alto are supported by public opinion when 
they take advantage of the presence of men expert in pure and 
applied science, and for appointment to the Board of Health 
select from such those whose training peculiarly fits them for 
taking part in the work of sanitation. The five branches of 
knowledge which, combined with a sense of public duty, are 
necessary and sufficient for the ideal board of health are rep- 
resented on the Palo Alto Board by a physician, an expert in 
bacteriology, an expert in physiological chemistry, an expert in 
disinfection, and a civil engineer who has made a considerable 
study of sanitary science and public health. 

Sanitary Measures in Palo Alto Since Epidemic, — Water 
Supply. — The distribution system of the Palo Alto water supply 
has been extended from time to time to keep pace with the 
rapid spread of building over outlying blocks. The increasing 
consumption of water has been met by sinking additional deep 
wells; the whole supply of water thus being drawn from 
artesian wells. Sewers. — The Palo Alto sewer system 

built in 1899 has shown no defect in design or construction. 
It is extended as rapidly as required by new buildings. When 
a building is erected on an outlying block to which the town 
sewer has not been laid, permission is granted the owner of the 
biiildincr to construct a cess-pool; but he is required to fill the 
ccss-i)ool and connect with the town sewer as soon as the lat- 
ter is laid in the adjacent street. Plumbing. — The 
plumbing ordinance^ passed early in 1901, has proved satis- 
factory. All new plumbing and plumbing repairs are care- 
fully inspected by the secretary of the Board of Health. 
Sanitary Patrol.— The secretary of the Board of Health 
carries on in conjunction with his duties as plumbing inspector 

* See Ordinances of Town of Palo Alto, 1905. 



TYPHOID FEVER AT PALO ALTO, CAL. 



15 



an effective sanitary patrol, on which he is from time to time 
accompanied by other members of the Board ; and all nuisances 
and insanitary conditions found are caused to be promptly 
removed. In most cases it has been found to be sufficient 
merely to call the attention of the owner or occupant of 
property to the unwholesomeness of its condition: such is 
the spirit of co-operation between the people and the Board. 

QuAEL\XTiXE AXD DisixFECTiox. — Sincc 1901 all 
cases of contagious and infectious disease have been promptly 
quarantined. At the time of raising the quarantine the prem- 
ises are thoroughly disinfected with formaldehyde by the sec- 
retary of the Board, free of charge. So far as known such dis- 
infection has proved effective. The books in the public library 
are periodically disinfected ; and in addition, those books which 
are returned to the Library from quarantined homes are dis- 
infected before they are returned to the shelves. (See Ap- 
pendix 1.) r^IiLK Supply. — At the time of the epidemic 
all dairies (in and outside of Palo Alto) supplying Palo Alto 
were inspected and the water supply and general arrangements 
at each dairy were put in such condition as to make them com- 
paratively safe. During the past two years a marked change 
for the better has been made in the sanitary condition at these 
dairies. Within the past five months all dairy herds of seven 
cows and upwards have been subjected to the tuberculin test 
by the veterinarian^ of the Board ; and as a result from 15 to 40 
per cent, of the cows of such herds have been condemned. 
Written instructions for disinfecting stables vacated by con- 
demned cows have been put in the hands of the dairymen con- 
cerned. Pearson's "Fifty Dairy Rules" amended to suit local 
conditions, has been printed and distributed among the dairy- 
men, and it is understood that in the future, renewal of the 
annual permit to sell milk in Palo Alto will be denied to those 
dairymen who have not complied with these rules. During 
the past year milk tests have been carried on at frequent irreg- 
ular intervals. The tests have been made to determine if 
the milk has been skimmed or watered. Examinations of 

^ The Board's veterinarian is the Assistant Professor of Veterinary Medicine and 
Bacteriology in the University of California- 



i6 



TYPHOID FEVER AT PALO ALTO, CAL. 



samples of milk to determine the number of bacteria has been 
unofficially begun by a member of the Board. It is planned 
to include the bacteria count in the regular tests in the near 
future. The experience of the past two years has discovered 
no defect in the milk ordinance.^ (See Appendix I.) 
Garden Products. — Nearly all gardens located within a radius 
of eight miles of and supplying Palo Alto have been inspected 
by the secretary of the Board with special reference to the 
supplies of water used in irrigating and preparing the products 
for market. It has so far been found impracticable to inspect 
the gardens producing those supplies which come from San 
Francisco and other distant places. Meats. — An 

effort to secure a U. S. inspector of meats did not succeed. 
The meat markets are inspected at irregular intervals by mem- 
bers of the Board on their rounds of the business blocks ; but 
such inspections are necessarily confined to general cleanliness 
in the markets. 

Present Sanitary Conditions at Stanford University. — The 
university Committee on Public Health through its chairman 
has made and compiled records of a comprehensive sanitary 
survey of the campus community, and of the boarding houses 
between Mayfield and Menlo Park (Fig. i) ; and students are 
not permitted to room or board in buildings the sanitary con- 
ditions of which are not approved by the Committee. 
The sanitary conditions of vegetable gardens supplying the 
campus are regularly inspected. Since all the milk used on 
the campus is furnished by a dairy which sells milk in Palo 
Alto, the campus residents enjoy the benefits of Palo Alto's 
dairy supervision. 

pari- IV. OPINION AND COMMENT. 

Tlu- preceding ])ages have been devoted to matters of fact. 
Some of the writer's opinions based on these facts and those 
presented farther on in the reports of Dr. Mosher and Dr. 
Snow, art' given here; others will be found in the Appendices. 

Cause of the Epidemic. — The Palo Alto epidemic of typhoid 

' Sec Orrliiianccs of tlic Town of Palo Alto, 1905. 

i 
1 



TYPHOID FEVER AT PALO ALTO, CAL. 1 7 

fever was caused by P. milk. This definite conclusion is com- 
pelled by the following consideration : 

Total number of cases in the epidemic 236 

Cases known to have used milk supplied by L. within 23 days previous 

to first symptoms 216 

Cases of apparent secondary infection (although all but two of these 

had used milk supplied by L.) 16 

Cases due to infection while patients were away from this community 

(Nos. I and 2, Appendix F) 2 

Cases having no known connection with milk supplied by L. or with 

previous cases in the epidemic (Nos. 3 and 4, Appendix F) 2 



The general geographical distribution of the users of the 
milk supplied by L. and of the cases of typhoid fever occurring 
in this community is shown in Fig. y (a diagrammatic map). 
The cases occurred indifferently in private homes, boarding 
houses, restaurants, lodging houses, dormitories and hotels : 
indifferently among male and female, children and adults; in- 
differently among all classes as determined by wealth or occu- 
pation ; indift'erently as regards sources of water supply and 
food supply (other than milk). On the other hand, 98^ per 
cent, of the typhoid fever patients had used milk supplied by 
L., and 26 per cent, of the users of milk supplied by L. had 
typhoid fever (see Fig. 8). 

The milk supplied by L. was from three sources: (i) The 
regular supply came from the P. dairy; (2) at times, extra' 
supplies came from the Palo Alto creamery; and (3) at times, 
extra supplies came from the Redwood City dairy (see p. 
and Figs, i and 8). The extra milk which L. got at 

times from the creamery cannot be considered as the cause of 
the epidemic, because among the many customers of the 
creamery who used none other than creamery milk there oc- 
curred no case of illness resembling typhoid fever. The extra 
milk and cream which L. got from the Redwood City dairy 
cannot be considered as the cause of the epidemic, because no 
case of typhoid occurred among those who used solely Red- 
wood Cit}^ dairy milk and cream. There is no alternative : P. 
milk was the cause of the epidemic. 

The statement that the P. milk was the cause of the epi- 
demic is independently justified by still another fact: The ep- 
idemic stopped with the stoppage of the use of P. milk, as is 
strikingly shown in Chart A, Fig. 5. 



i8 



TYPHOID FEVER AT PALO ALTO, CAL. 



In some of the earlier cases there was no connection with 
the P. milk evident at first, though further inquiry established 
this connection. The first case of this kind was among the 
first half dozen reported, and is of peculiar interest, inasmuch 
as it tended to upset the theory of the Board of Health that 
the P. milk was the source of the trouble, and caused them to 
continue in all directions their search for some other possible 
source of infection, even after the closing of the P. dairy. 

Certain interesting additional facts which vvhen known only 
in part, had some weight against the P. milk theory but which 
now wholly known, have no such significance, are given in 
Appendix G. 

Secondary Infection. — The cases of secondary infection 
were relatively few (see p. 35). This may be attributed to: 
the safe water supply ; the excellent sewer system and modern 
plumbing; the generally clean condition of the- community ; 
the fact that every case of fever was under the care of a pro- 
fessional nurse ; the disinfection of the premises of each case 
on raising the quarantine and the fact that suspected cases 
were, after the first, treated as real until proved to the con- 
trary. 

Safety of Public Health at Palo Alto and Stanford Univer- 
sity. — The natural drainage of the site of the Palo Alto and 
University community is good ; the artesian sources of water 
supply are in no danger of pollution ; the sewer systems are 
well designed and well built. The community was started in 
1891, and for this reason there is no antiquated plumbing. 
Shallow wells, cesspools and privies are practically nonex- 
istent here.^ The milk supply and the contributing 

1 The sanitary advantage of youth to Palo Alto becomes clearly apparent on 
reading Dr. George A. Soper's paper ^ on the epidemic of typhoid fever (1,350 cases 
in a population of 13,000) at Ithaca, N. Y., which v/as saddled virith old-time sanitary 
arrangements, notwithstanding the fact that the city had for many years enjoyed a 
genera! water supply system, and since 1896 a system of sewers. Dr. Soper says: 
"[Ithaca at the time of the epidemic] contained about 1,300 wells and nearly an equal 
number of privies. ♦ ♦ * The Board of Health itself spent $10,000. The privy 
cleaning cost $5,000 more; the inspection and plumbing improvements of students' 
boarding houses are estimated to have cost $](t,00() additional. In the Palo Alto epi- 
demic the Board of Health expended $350, $300 of which was paid out for bacteriolog- 
ical examination of milk and water. The New York State Board of Health sent to 
Ithaca a sanitary expert who directed the work of the local Board of Health, but the 
writer does not know whether lie was paid by the city or the State. The Palo Alto 
Board of Health were less fortunate, having no expert counsel either paid or unpaid. 

2 Jour. N. E. Water Works Ass'n, Vol. XVIU, No. 4. 



TYPHOID FEVER AT PALO ALTO, CAL. 



19 



dairies (both in and outside of Palo Alto) with their water 
supplies and herds, are under careful supervision. An attempt 
is made to investigate the conditions under which the sup- 
plies of vegetables are raised. Cases of contagious disease 
are promptly quarantined, and the premises are thoroughly 
disinfected. Finally the people by reason of their costly ex- 
perience are awake to the value of knowledge, alertness, and co- 
operation in sanitary matters. Having in mind these 
elements of the present sanitary conditions and some knowledge 
of the progress which sanitary science has made up to this time, 
the writer is forced to conclude that the public health of the com- 
munity of Palo Alto and Stanford University is safeguarded to 
a marked degree. 

PART V. AN ANALYSIS OF CASES. 

(Made for the Board of Health of Palo Alto by 
CLELIA DUEL MOSHER/ A. M., M. D.) 

Number of Cases; Age; Sex. 

Number of Cases. — The total number of cases of typhoid 
fever reported to the Board of Health of Palo Alto was 216. 
The detailed reports^ of these cases showed 4 cases reported 
twice by dif¥erent physicians which reduced the number to 
212. In one case the corrected diagnosis of meningitis re- 
duced the total number to 210. Of this number 36 were out- 
side of the corporate limits of the town ; leaving the total num- 
ber of cases occurring within the limits of the town 174. There 
were, however, 2 cases within the limits of the town not re- 
ported by the physician ; this makes the total number of cases 
in the town of Palo Alto 176. 

Twenty-four known cases for which no detailed reports 

1 Formerly Instructor in Hygiene in Stanford University, Externe in the Johns 
Hopkins Hospital, and Gynaecological Assistant in Dr. H. A. Kelley's Sanitarium, 
Baltimore, Md. 

- This analysis is based on the reports of the physicians returned on the special 
typhoid fever blanks (Appendix B) sent them, supplemented by statements gathered 
from the families and individuals affected, together with a study of the death records. 
Every supplemental statement has been verified as far as possible. The diagnoses and 
statements of the physicians have been accepted as final. 



20 



TYPHOID FEVER AT PALO ALTO, CAL. 



were obtained, occurring among students who had left Palo 
Alto and vicinity after the outbreak of the epidemic, were 
scattered from New York to Oregon and Southern California. 
Adding these 24 cases to the 210 cases for which detailed re- 



PALO ALTO 
TYPHOID FEVER EPIDEMIC 

1903 

208 CASES 

ARRANGED IN 

AGE GROUPS 



CVI 

I 

o 



lO 



I 

CM 



I 

o 



o 

CM 



in 

CM 
» 

O 



CO 



o 



o 



o 
I 

lO 

NT 



Age Raimges (Years) 
FIG. 4. 



ports were obtained from physicians, makes the total number 
of cases in the Palo Alto epidemic 236. 

For purposes of statistical study of the character of the 
epidemic all of the 210 cases reported have been included. 

Before taking up the detailed analysis of these cases it will 
be well to consider the ch"stribution of the cases of typhoid 
fever over the period of the epidemic as graphically shown in 
Fig. 5. In Chart A of Fig. 5 the number of cases showing 



ne. 5 



UJ 

1.0 5 



0.5 



z 
< 



0.0 




il 



ID 



■III I II 



in 



cuojCViPJoJ cucuojfupjtotO 



1903 



TYPPIOID FEVER AT PALO ALTO, CAL. 



21 



1st symptoms on each day of each month is indicated by the 
heavy black vertical line drawn just above that date. In 
Chart B of Fig.. 5 the length of each heavy black vertical line 
indicates the number^ of cases which received the physician's 
first visit on the date printed immediately below that line. 
(Chart C, Fig. 5, represents the rainfall on the several dates.) 

Age. — The ages of the patients were reported in 208 of the 
210 cases. These varied from five months to 60 years. Fig. 4 
shows distribution of cases according to age groups. There 
is probably in Palo Alto and vicinity an average number of 
children to the population ; in the age group between 15 and 
30 years, — the most susceptible age for the typhoid infection, 
— the number of persons is undoubtedly far above the average 
in this, a university community. The fact that the source of 
infection was milk probably accounts for the large number of 
cases in little children. 

Table I. — Distribution According to Age Groups in 208 Cases of Typhoid 
Fever in Palo Alto Epidemic 



AGES 

2 years and under. . . 

2 to 5 years 

5 " lo " 

10 " 15 " 

15 " 20 " 

20 " 25 " 

25 " 30 " 

30 " 35 " 

One hundred and fifteen cases of typhoid fever in the Mont- 
clair, N. J., epidemic in 1894, included 3 children under 2 years 
old (about 2.6 per cent, of the total cases). In the epidemic 
at Stamford, Conn., in 1895, there were 406 cases and 4 chil- 
dren under 2 years of age, i. e. about i per cent. Among the 

^ In 204 of the 210 cases the date of onset of symptoms was given and in 205 of 
the 210 cases the date of the physician's first visit was reported. 



No. of Cases 
in Palo Alto 



4 
10 
20 
20 
40 

51 
26 

12 



AGES 



35 to 40 years 
40 " 45 " 
45 " 50 " 
50 " 55 " 
55 " 60 " 

Total 



No. of Cases 
in Palo Alto 



208 



22 



TYPHOID FEN'ER AT PALO ALTO, CAL. 



Palo Alto cases there were 4 children under 2 years. Ogle 
has reported typhoid fever in one child 4^ months old; Mur- 
chison, in a child of 6 months ; and Fuller, in a child of 9 
months. In the Palo Alto epidemic there was one patient 5 
months old. Since typhoid fever in such very young chil- 
dren occurs so seldom the history of such cases in the Palo 
Alto epidemic has been included. 

Case 141.^ — Female, Aet. 5 months. Symptoms : Vomiting, fever high 
( 105-5° )> pain in bowels, diarrhoea and constipation, profuse eruption, 
spleen not palpable. Widal reaction negative twice. Osteitis of first 
finger fairly early in disease. Child nursed by mother, who developed 
symptoms 17 days before baby's first symptoms. 

Case 42. — Female, Aet. iK> years. Symptoms: Vomiting, headache, 
fever, pain in bowels, epistaxis, constipation, delirium, eruption. No 
Widal reaction made. Patient discharged by physician on 45th day 
of illness. 

Case 117. — Male, Aet. 2 j^ears. Symptoms: Chills, headache, fever, 
pain in bowels, epistaxis, tongue coated, eruption present. No Widal 
reaction made. 

Case 156. — Female, Act. 2 years. Put to bed and physician's first visit on 
14th day of illness. Previous health good. Symptoms : Headache, 
fever, pain in bowels, diarrhea, eruption present. No Widal reaction 
made. Complications : — Sm.all intestinal haemorrhage. 

There were in the Palo Alto epidemic 54 persons under 16 
years of age. In Table II a comparison is made between these 
54 cases and Dr. Holt's 970 case (reported by 8 writers) of 
the same age range. 

Table II.— Cases of Typhoid Fever in Persons under 16 years : 54 Palo Alto 
Cases Compared with Dr. Holt's ^ 970 Cases 





54 Palo Alto Cases- 


-15 years and 


Dr. Holt's 970 Cases 




under 


15 years and under 


AGE GROUPS 










No. 


Per Cent 


Per Cent 


5 years and under 


14 




26 


8 




20 




37 


42 




20 




37 


50 


Total 


54 


100 


100 



* The numbering of the cases is entirely arbitrary and has no relation to time of 
occurrence, or location of cases. 

•Holt, Dr. L. Kmmett: Diseases of Infancy and Childhood, p. 1008. 



TYPHOID FEVER AT PALO ALTO, CAL. 



23 



Sex. — Of the 210 cases of typhoid fever loi (48 per cent.) 
were females, and 109 (52 per cent.) males. 

Symptoms. 

Chills. — In 26 cases this question was not answered. 68 of 
the cases did not have chills. 100 cases had chills ; 6 cases, slight 
chills ; and 10 cases, chilly sensations. 

Vomiting. — In 26 of the 210 cases, the question of whether 
vomiting was present or not was not answered. In iii cases 
there was no vomiting. In 73 cases vomiting occurred. Of 
these 73 this symptom was stated in 2 cases to be slight; in I 
case there w^as occasional vomiting. In 2 cases vomiting was 
a marked symptom ; and in one of these the vomiting was due 
to an infection of the gall bladder. 

Headache. — In 26 cases this question was not answered. 
In 4 cases there was no headache; in 180 cases headache was 
present. 

Pain in the Bowels. — In 26 cases this question was not 
answered. 27 cases had no pain in the bowels: and of the 157 
cases in which pain was present, in 3 it was reported as slight, 
in I as moderate, and in 2 as marked. 

Epistaxis. — In 26 cases this question was not answered. 
There was no epistaxis in 55 cases. In 129 of the 210 cases, 
this symptom^ was present ; in 4 cases it was said to be slight, 
and in i, severe. 

Diarrhoea and Constipation. — In 26 cases this question 
was not answered. Diarrhoea was present in 29 cases. Osier 
gives the frequency of diarrhoea as from 25 to 30 per cent. 
There were 10 cases in which both diarrhoea and constipation 
occurred. There was no diarrhoea in 50 cases, but the phy- 
sicians did not report whether or not constipation was present 
in these 50 cases. 95 cases were reported as constipated. 

Delirium. — This question was not answered in 24 cases. 
There was no delirium in 102 cases. 84 cases had delirium ; 
slight in 9 and marked in 7 cases. In i case the delirium was 
reported as "soon passing into stupor." It was prolonged in 
I case, and in i there was mild post-typhoid mania. In 3 cases 
it was reported as associated with high temperature. 



24 ■ TYPHOID FEVER AT PALO ALTO, CAL. 

Eruption. — This question was not answered in 26 cases. 
There was no eruption in 16 cases. In 168 cases the eruption 
was present. Of these, in 6 it was slight or scanty ; in 16 
marked or abundant. In i case there was a vesicular eruption 
follow^ed by desquamation. 

Case 158. — Female, Aet. 11. Took to bed and physician's first visit on third 
day of illness. Previous health good. Symptoms : Chills slight, head- 
ache, fever 104° — irregular characteristic curve, pain in bowels, 
epistaxis, constipation, tongue heavily coated, spleen palpable, eruption 
— "a vesicular erythema which appeared about the loth day of illness 
and which covered the entire body"; this was followed by a desquama-- 
~ tion. Patient discharged by physician on 50th day of illness. 

Spleen. — The condition of the spleen was not reported in 132 
cases. The spleen was not palpable in 10 cases ; palpable in 68 
cases. 

WiDAL Reaction. — The Widal Reaction was not made in 184 
cases. This reaction was negative in i case, date not given : 
negative twice in Case No. 141, child aet. 5 months; negative 
twice in Case No. 144; and twice in Case No. 136 where death 
occurred from miliary tuberculosis following the typhoid at- 
tack. Case No. 187 was positive on 4th day, and several times 
after. Case No. 188, negative on the 8th day and positive on 
the 9th. Case No. 147 negative on day of going to bed and 
positive 3 days later. Case No. i was suggestive on the 3d 
day and positive on the 33d day. The following were posi- 
tive : 

DAY ON WHICH DAY ON WHICH 

CASE NO. POSITIVE. CASE NO. POSITIVE. 

150 4th. 81* 25th. 

18 loth. 133 25th. 

16* 19th. 134* 28th. 

19* 20th. 32* 32d. 

20* 2 1 St. 17* 34th. 

82* 22d. 30* 35th and 69th. 

27* 24th. 84* 40th. 

No statement was made by the physician reporting the 
cases (marked *) of previous negative reactions, nor was 
reason assigned for waiting until so late in the disease before 
testing the Widal reaction of these cases. 

Temperature. — In 36 cases no report in regard to tempera- 



TYPHOID FE\'ER AT PALO ALTO, CAL. 



25 



ture was made ; 3 were reported as subnormal. The afebrile 
type of typhoid is rare in this country. Osier did not have a 
single case among the 685 which he has analyzed. Fisk of 
Denver has seen it. 

Case No. 174. — ]\Iale, Aet. 33. Went to bed on 7th day of illness; did not 
see physician until i6th day. Physician reports this case as ambulatory 
for most part. Symptoms : Chilly sensations, headache, temperature 
subnormal for weeks, pain in bowels, epistaxis, constipation, eruption 
present. Xo Widal reaction made. 

Case Xo. 163. — ]^Iale, x\et. 22. Took to bed on physician's ist visit, 21st 
day of illness. Symptoms : Chills, headache, temperature subnormal, 
pain in bowels, epistaxis, constipation, eruption present. Xo Widal re- 
action made. Complications : Hsem.orrhoids. 

Case X^o. 137. — ^lale, Aet. about 40. Took to bed on doctor's ist visit on 
i6th day. Symptoms : Chilly sensations, headache, subnormal tem- 
perature, pain in bowels, epistaxis, constipation, eruption present. No 
Widal reaction made. Xo complications. Patient discharged on 40th 
day of illness. 

Case No. 199. — ]\Iale, Aet. 20. Took to bed and physician's ist visit on 
1st day of illness. Previous health good. Symptoms: Headache, 
temperature below 104° for 4 weeks, then up to 103° for 3 weeks, then 
102'' for 2V2 weeks; pain in bowels, epistaxis, no diarrhoea, delirium, 
eruption present. 

One case was reported malarial in type at onset, but typical 
later. 51 cases were reported as typical; of these 8 had low, 
slight or moderate fever, and 9 had high fever. 

The maximum temperature was given in 26 cases and was 
as folloAvs : 

TEMPERATURE. XO. OE C.^SES. TEMPERATURE. NO. OE CASES. 

i02°.8 I io5°.4 I 

103° I I05°.5 5 

104° 5 106° I 

i04°.2 I io6°.4 I 

i04°.6 I 107° I 

105° 5 

The range given in 3 cases was as follows : 

95° to io6°.4 1 case 

103° to 105° I " 

104° to 105° I " 

Recrudescence. — Elevations of temperature during con- 
valescence, not constituting a relapse, were reported in 13 
cases. 

Case X^o. 7. Fever characteristic, highest temperature 104°. 2. Onset with 
follicular tonsillitis with fever of usual type except fever continued 



26 



TYPHOID FEVER AT PALO ALTO, CAL. 



after disappearance of local symptoms. Recrudescence after 3 days of 
normal temperature, duration 8 days. 

Case No. 8. Fever described as not high — 103° ; 10 weeks of fever. After 
4 days of normal temperature, recrudescence lasting 8 days ; second 
recrudescence after 3 days normal temperature, duration 2 weeks. 

Case No. it. Characteristic temperature curve; recrudescence after several 
days of normal temperature, then higher temperature with delirium. 

Case No. 12. Long run of typical fever, then few days of normal tem- 
perature, then temperature went to 104°. Due to otitis media. 

Case No. 23. Temperature 107°, range high, regular at first, then dropped 
to normal ; recrudescence. 

Case No. 32. Ver}' high temperature — io6°.4 maximum, recrudescence. 

Case No. 34. Typical fever for 4 weeks, then normal for 4 days ; climbed 
higher gradually ; normal again at end of 2 weeks. 

Case No. 37. Characteristic fever curve for 4 weeks ; normal temperature 
for several days ; persistent recrudescence. JMalarial organisms found 
in blood during recrudescence. 

Case No. 38. Fever characteristic, mild, slight recrudescence after 4 days 
of normal temperature. 

Case No. 39. Mild course of fever for 4 weeks ; 3 days of normal tem- 
perature, then recrudescence with hyperpyrexia. 

Case No. 72. Recrudescence after several days of normal temperature. 

Case No. iii. Temperature range 99° to 100° — a few times going to 101° 
for 4 weeks ; spleen palpable but no eruption. Then temperature 
high, eruption on chest and abdomen, rapid irregular pulse. Mild 
recrudescence after several da3^s of normal temperature. 

Case No. iiS. Temperature typical and high — 106°. Slight recrudescence 
once or twice. 

Relapse.^ — Relapse was reported in 13 cases. Cases Nos. 
17, 19, 20, 169, 30 (fatal, see under Complications) stated only 
that relapse occurred. 

Case No. 5. Mild case for 4 weeks ; characterized by irritable stomach 
most of the time ; normal temperature for 4 days, and then relapse 
lasting for 4 weeks. 

Case No. 27. Had high temperature and profuse epistaxis. 

Case No. 84. Had high temperature; enlarged liver; complications. 

Case No. 130. (Fatal, see under Complications.) 

Case No. 187. One relapse after 14 days of normal temperature. 

Case No. 159. Temperature not high; relapse after several days of normal 
temperature, duration 3 weeks, temperature higher than in first run of 
fever. 

Case No. 195. Male, Aet. 30. Previous health fair. Took to bed and 
physician's ist vi.sit on 3d day of illness. Symptoms: Chills, head- 
ache, fever, pain in bowels, epistaxis, no diarrhoea, delirium, eruption 



TYPHOID FEVER AT PALO ALTO, CAL. 



27 



present. No Widal reaction made. Complications : "Went to San 
Francisco, then returned with a diagnosis of 'not typhoid.' Had chill, 
followed by high fever and relapse for 6 weeks." 

Case No. 109. — Relapse. Nervous shock suggested as the cause. The 
percentages of relapses vary. Murchison gives 3 per cent. ; Baumler, 
II per cent; Immermann, 15 to 18 per cent. In Wagner's clinic from 
1882 to 1886 there were 49 relapses in 561 cases (9 per cent.). In 
Osier's 685 cases there were 54 relapses (8 per cent). In the Palo 
Alto cases there were reported 13 relapses (6 per cent.). 

Complications. 

Collapse was reported in 12 cases. Endocarditis 
was reported in six of the 210 cases in the Palo Alto 
epidemic ; and in one case it was given as the cause of 
death. Thayer^ states that endocarditis is rare and unim- 
portant. There were ii cases of endocarditis in 2,000 nec- 
ropsies in Munich. In the 210 cases of the Palo Alto 
epidemic weak heart was reported twice ; venous thrombosis 
in one case ; phlebitis in three cases. Thayer gives 38 cases of 
venous thrombosis in 1,458 cases of typhoid fever, — 2.6 per 
cent. Mitral disease was found twice. 
Arterio-sclerosis was found in one case. Tonsillitis 
was reported in three cases ; pneumonia, in six cases ; bron- 
chitis, in one case ; and miliary tuberculosis, in one case. 

One case was reported very nervous. 
Cerebritis was reported in one case. Meningeal com- 

plications occurred in two cases. Prolonged delirium 

occurred in one case. Post-typhoid mania occurred 

in two cases. Appendicitis was reported in one case; 

perforation, in four cases (discussed on p. 32 and p. 34) ; 
tympanites, in one case ; peritonitis, in one case ; intestinal 
haemorrhages in 26 cases (discussed on p. 28 and p. 34) ; 
haemorrhoids in one case. Infection of gall bladder 

was reported in tw^o cases. Arthritis and rheumatism 

were reported in one case ; and rheumatism in one case. 

Osteitis occurred in two cases. Osier states that 
bone lesions are more common as sequelae in children than in 
adults. It is interesting that one case of osteitis of the index 

^Thayer, William Sidney: On the Cardiac and Vascular Complications and 
Sequels of Typhoid Fever — Johns Hopkins Bulletin, Vol. XV, p. 323 et seq. 



28 



TYPHOID FEVER AT PALO ALTO, CAL. 



finger occurred in the youngest case, — aet. five months — , in 
the Palo Alto epidemic. Acute nephritis occurred 

in one case; albumen and casts in urine, in one case; and 
subacute cystitis, in one case. Abscesses were re- 

ported as follows : Ischio-rectal, one case ; rectal, one case ; 
axillary, in one case ; arm, one case. 

Osier states otitis media to be a not infrequent complica- 
tion, occurring in about 2.5 per cent of the cases collected by 
Hengst, with only one case of involvement of the mastoid. 

Among the cases in the Palo Alto epidemic, otitis media 
was reported in 3 cases (1.4 per cent.), with one case in which 
the mastoid was involved. 

Pregnancy. — Osier states that typhoid fever in preg- 
nancy is rare. In his 685 cases only one case of "pregnancy 
occurred. Among the 210 Palo Alto cases, there were three 
cases of pregnancy. In two cases delivery took place one 
month early: In the ist case the child was poorly nourished 
and had high temperature ; in the 2d case the child's temper- 
ature was normal; both children lived; in the 3d case the 
child lived one month. All the mothers recovered. The mor- 
tality in pregnant women is high, — according to Brieger, 21 
per cent, in 91 cases, and 17 per cent, in Vinay's 183 collected 
cases. 

Exophthalmic Goitre. — One case of exophthalmic goitre 
had typhoid fever. 

Malaria. — In three cases the malarial organisms were 
found in the blood, — in Case No. 10 (see under Haemorrhage), 
Case No. 37 and Case No. 144. 

Case No. 37. Symptoms : Headache, characteristic temperature curve for 
4 weeks, pain in bowels, constipation, tongue coated, no eruption, spleen 
palpable. Normal temperature for several days followed by persistent 
recrudescence. Malarial organisms found in blood during recrudes- 
cence. 

Case No. 144. Female, Aet. 23. Symptoms : Chills, vomiting, headache, 
fever, pain in bowels, diarrhoea, tongue brown, delirium, no eruption. 
Widal reaction made — never positive. All clinical symptoms pointed 
to typhoid. Aestivo-autumnal organisms found in blood. Complica- 
tions. Malaria. Great loss of weight and falling of hair. 

Haemorrhage. — There were 25 cases in which haem- 



TYPHOID FEVER AT PALO ALTO, CAL. 



29 



orrhage occurred, or, if we include one case (No. 45) in which 
a few specks of blood occurred, we have 26 cases (8 per cent, 
of the 208 cases considered). Osier gives the frequency of 
haemorrhage as ranging from 3 to 5 per cent, in all cases. 
In his own 685 cases there were 33 cases of haemorrhage. Ac- 
cording to Osier 30 to 50 per cent, of cases having haemor- 
rhage are fatal. In the Palo Alto cases in which 8 per cent, 
had haemorrhage, only seven of these haemorrhage cases 
died, or 27 per cent, of the cases having intestinal haemorrhage 
proved fatal. In the cases of haemorrhage there were 15 
women and 11 men. The ages are of sufficient interest to 
• examine closely. 



26 CASES OF 


INTESTINAL 


HAEMORRHAGE IN 


PALO ALTO EPIDEMIC 


OF TYPHOID 


FEVER. 


AGES. 


MALE. 


FEMALE. 


AGES. MALE. 


FEMALE. 


2 





I 


25 


I 


P 


4 


I 





29 


I 





10 





I 


32 





I 


12 





I 


35 


2 


•0 


15 





I 


36 





I 


17 





I 


38 







18 





I 


40 





I 


20 


I 


2 


56 





I 


22 


3 


I 








23 


I 


I 


Total 


II 


15 


24 


I 












It has seemed worth while to give a brief account of each 
case in which haemorrhage took place. 



Case No. 156. Female, Aet. 2. Patient put to bed and doctors ist visit 
on 15th day of illness. Previous health good. Symptoms : Headache, 
fever, pain in bowels, diarrhoea, eruption present. No Widal reaction 
made Complications : Small haemorrhage. 

Case No. 114. Male, Aet. 4. Patient put to bed and doctor's ist visit 
14th day of illness. Symptoms : Headache, fever, pain in bowels, epis- 
taxis, diarrhoea and delirium, eruption present. No Widal reaction 
made. Complications : Endocarditis, very rapid irregular pulse, con- 
vulsions, collapse and 2 intestinal haemorrhages. 

Case No. 161. Female, Aet. 10. Went to bed 3 weeks after ist symp- 
• toms ; doctor's ist visit 3 weeks later. Symptoms: Chills, vomiting, 
headache, fever, pain in bowels, cpistaxis, diarrhoea, delirium, erup- 
tion present, spleen palpable. Complications : Rheumatism, and i in- 
testinal haemorrhage. 

Case No. 13. Female, Aet. 12. Physician's ist visit and took bed on ist 
day. Delicate child. Symptoms: Vomiting, headache, high fever, pain 
in bowels, epistaxis, constipation first 3 weeks, diarrhoea 4th and 5th 



3a TYPHOID FEVER AT PALO ALTO, CAL. 

weeks of illness ; tongue coated, delirium for 3 weeks, difficult to con- 
trol; eruption present, spleen palpable. No Widal reaction made. 
Complications : Intestinal haemorrhage of 6 ounces in 4th week. 

Case No. 81. Female, Aet. 15. Took to bed and physician's ist visit on 
14th day of illness. Symptoms : Headache, fever, pain in bowels, epis- 
taxis ; eruption present. Widal reaction positive on 25th day of illness. 
Complications : Small intestinal haemorrhage. 

Case No. 72. Fem.ale, Aet. 17. Took to bed on 2d day of illness, physi- 
cian's ist visit on ist day. Symptoms : Chills, headache, fever high, 
characteristic temperature curve for 16 days, pain in bowels, no 
epistaxis, constipated, tongue slightly coated, slight delirium, eruption 
present, spleen palpable. Complications : Intestinal haemorrhage about 
8 ounces on i6th da}^, with temperature 96°, pulse feeble and rapid. 
]\Iild secondary rise of temperature after several days of normal tem- 
perature. 

Case No. 169. Female, Aet. 18. Went to bed and ist visit of physician on 
14th day of illness. Widal reaction positive (date not given). Com- 
plications: Mitral lesion; bleeding from all the mucous membranes; 
profuse epistaxis for weeks ; constant intestinal haemorrhage for about 
5 weeks ; relapse. 

Case No. 184. Female, Aet. 20. Patient went to bed on 2d day of illness. 
Doctor's 1st visit on 2d day. Previous health good. Symptoms : 
Chills, vomiting, headache, fever, pain in bowels, epistaxis, constipa- 
tion, delirium, eruption. Widal reaction not made. Complications : 
Severe intestinal haemorrhages ; died on 20th day of illness. 

Case No. 45. Female, Aet. 20. Took to bed on 3d day of illness, phy- 
sician's 1st visit on 4th day. Symptoms : Chills, vomiting, headache, 
fever high continuously, pulse proportionally very rapid, pain in bowels, 
epistaxis, constipation, tongue coated, delirium marked, eruption 
marked, spleen palpable. No Widal reaction made. Complications: 
Few specks of blood in stools once. "First sound of heart flattened 
out until it could not be heard; extrem.e nervous symptoms becoming 
more marked." Died on 24th day of illness. 

Case No. 46. ]\Iale, Aet. 20. Took to bed on 3d of illness. Physician's 
1st visit on 4th da}'. Symptoms: Chills, vomiting, headache, fever, 
pain in bowels, epistaxis, both diarrhoea and constipation, character- 
istic tongue, delirium, eruption present, spleen palpable. No Widal 
reaction made. Complications : Intestinal haemorrhage. 

Case No. 192. Male, Aet, 22. Took to bed and physician's ist visit on 
5th day of illness. Previous health fairly good. Symptoms: Qiills, 
vomiting, headache, fever, pain in bowels, epistaxis, no diarrhoea, de- 
lirium, eruption present. No Widal reaction made. Complications: 
Severe intestinal haemorrhages and two perforations, four days apart. 
Died on 21st day of illness. Autops3\ 

Case No. 36. Female, Aet. 22. Mild typhoid infection. Health before 
present illness poor. Exophthalmic goitre. Patient took to bed on 2d 
day of illness. Physician's ist visit on 3d day. Symptoms : Chills, 
persistent nausea and vomiting, headache, temperature never high, 
pulse too rapid to count. (Pulse for past 3 years ranged from no 
to 140.) Diarrhoea, tongue not characteristic, eruption not present, 
spleen not palpable. Widal reaction not made. Complications : Small 
intestinal haemorrhage about 2 ounces, in 3d week of illness. Death 
from e\bau«^tion. 



TYPHOID FEVER AT PALO ALTO, CAL. 



31 



Case No. 106. Male, Aet. 22. Took to bed and physician's ist visit on 
ist day of illness. Symptoms not reported. Complications : 2 in- 
testinal haemorrhages : first of i pint, and second of ^ pint. 

Case No. 17. Male, Aet. 22 First visit of physician and took to bed on 
14th day of illness. Symptoms : Headache, fever, pain in bowels, 
epistaxis, delirium, eruption slight, spleen and liver enlarged. Widal 
reaction positive, 34th day of illness. Complications : Several col- 
lapses; 2 intestinal haemorrhages; mitral disease. 

Case No. 175. Female, Aet. 23. In bed i day at onset of illness, then up 
about I week. Symptoms : Chills, vomiting, headache, fever, pain in 
bowels, epistaxis, diarrhoea alternating with constipation, delirium. 
No Widal reaction made. Complications : Haemorrhages, from nose, 
bladder^ kidney, stomach and bowels. Died on 64th day after phy- 
sician's 1st visit. 

Case No. 18. Male, Aet. 23. Physician's ist visit and took bed on 7th 
day of illness. Symptoms : Chilly sensations, headache, pain in bow- 
els, epistaxis, constipation, eruption present. Widal reaction positive 
on lOth day of illness. Complications : Severe intestinal haemorrhages. 

Case No. 10. Male, Aet. 24. Took to bed and doctor's ist visit on 5th day 
of illness. Previous health fairly good. Symptoms : Chills, vomiting, 
headache, high fever from onset, pain in bowels, epistaxis, constipation, 
tongue typical, "delirium from beginning, soon merging into stupor ; 
eruption abundant over abdomen, chest and back, very like papular 
sj^philide;" spleen palpable. No Widal reaction made. Complications: 
Intestinal haemorrhage in 4th week, 14 ounces; temperature 96°, 
pulse 160, marked collapse ; 5 days later, violent chill with ice-cold ex- 
tremities, then pulse too rapid to count, followed by subnormal tem- 
perature, and pulse 50. Endocarditis ; abscess in axilla — later, a sec- 
ond development. Malarial organisms in blood, typical malarial at- 
tack 2 years before. 

Case No. 194. Male, Aet. 25. Took to bed and physician's ist visit on 
3d day of illness. Previous health good. Symptoms : Chills, head- 
ache, fever, pain in bowels, epistaxis, diarrhoea, delirium, eruption 
present. No Widal reaction made. Complications : Haemorrhages. 

Case No. 112. !Male, Aet. 29. Took to bed and physician's ist visit on 
3d day of illness. Previous health good. Symptoms : Chills, headache, 
fever, pain in bowels, epistaxis, constipation, characteristic tongue, de- 
lirium, eruption present, spleen palpable. No Widal reaction made. 
Complications: Intestinal haemorrhage of about 12 ounces on the 15th 
day with m.arked collapse. 3 days later profuse discharge of blood 
from bowels, and collapse. "There had been capillary oozing from 
ist and 2d haemorrhages shown by character and amount of blood 
passed." Patient did not react at all after ist haemorrhage, feeble, ir- 
regular pulse and bloodless. Recovered. 

Case No. 41. Female, Aet. 32. Took to bed on 4th day of illness. Doc- 
tor's 1st visit on 5th day. Previous health always delicate. Symptoms: 
Chills, slight headache, fever, epistaxis, no pain in bowels, diarrhoea, 
tongue very red, eruption present. No Widal reaction made. Com- 
plications : Slight capillary haemorrhage from bowels. 

Case No. 122. Male, Aet. about 35. Patient went to bed at onset of symp- 
toms, and called physician on ist day. Symptoms: Qiills, vomiting, 
severe headache, temperature 104°, pain in bowels, no epistaxis, con- 
stipation, tongue typical, delirium, eruption marked, spleen palpable. 



32 



TYPHOID FE\T,R AT PALO ALTO, CAL. 



No Widal reaction made. Complications : Intestinal haemorrhage, 
about I pint on 17th day of illness; enormous Ischio-rectal abscess. 

Case No. 130. Male, Aet. 35. Patient took to bed and physician's ist 
visit on 4th day. Previous health good. Symptoms : Chills slight, 
headache, fever, diarrhoea, tongue yellowish-brown, eruption present 
No Widal reaction made. Complications : Haemorrhages, pneumonia, 
weak heart, peritonitis. "Patient had 2 relapses, the last proving fatal 
on the 48th day of illness." 

Case No. 181. Female, Aet. 36. Took to bed and physician's ist visit on 
2d day of illness. Sjanptoms : Chills, marked vomiting, headache, fe- 
ver, pain in bowels, diarrhoea, delirium, eruption. No Widal reaction 
. made. Complications : Endocarditis, degeneration of liver, intestinal 
haemorrhage. Died on 75th day of illness. 

Case No. no. Female, Aet. 38. Took to bed and physician's ist visit on 
3d da)^ Previous health only fairly good. Had had frequent malarial 
attacks. Symptoms : Chills, vomiting, headache, typical fever curve, 
pain in bowels, constipation, characteristic tongue, eruption scanty, 
spleen palpable. No Widal reaction made. Complications : Intestinal 
haemorrhage, about 6 ounces on 19th day with slight collapse, second 
haemorrhage of about 4 ounces i week later. "Coughed muclv in 
early convalescence, large quantities of purulent matter containing 
streptococci and staphylococci ; no tubercle bacilli found. Ran an 
afternoon tem.perature of undoubted pulmonary origin for several 
weeks. Discharged in 8th week in as good condition as before onset 
of illness." 

Case No. 159. Female, Aet. about 40. Patient went to bed and physician's 
1st visit about 2 weeks after onset of illness. Symptoms: Chills, head- 
ache, typical temperature curve, slight pain in bowels, much epistaxis, 
characteristic tongue, no eruption, spleen not palpable, very nervous. 
At the end of ist 3 weeks patient tried to get up and look after other 
members of the family ill (4 other cases in house). Second rise of 
temperature higher than first course of fever. Slight amount of blood 
in stools twice. 

Case No. 128. Female, Aet. 56. Took to bed and ist visit of physician 
about 2 weeks after onset of illness. Symptoms : Chills, vomiting, head- 
ache, typical temperature curve, slight pain in bowels, much epistaxis, 
diarrhoea, tongue typical, sliglit delirium, eruption marked, spleen pal- 
pable. Widal reaction not made. Complications : Arterio-sclerosis, 
albuminuria with a few granular casts; intestinal haemorrhage (i^/4 
pints of clots) at beginning of 3d week of illness. 

Perforation. — Perforation occurred in five of the fatal 
ca.ses in Palo Alto epidemic. 

Case No. 193. Male, Aet. 20. Took to bed on 7th day of illness; physi- 
cian's 1st visit on 8th day. Previous health fairly good. Symptoms: 
Chills, vomiting, headache, fever, pain in bowels, epistaxis, no diar- 
rhoea, delirium, eruption present. No Widal reaction made. Com- 
plications : Perforation and meningeal symptoms. Died of perforation 
on 20th day of illness. 

Case No. 120. Male, Aet. 34. Perforation on 2d day after admission to 
hospital, and 17th day of illness. Patient had eaten full meal of beef 
steak, etc., on the day before admission. This case died before prepa- 
ratifjn for operation rould be completed. Autopsy: Spleen enlarged, 
heart, lungs and bladder normal ; brain not examined. Intestinal tract 



TYPHOID FEVER AT PALO ALTO, CAL. 



33 



showed typical ulcers and small perforation in ileum about inches 
from the ileocoecal A'alve. Some 12 ulcers in intestine noted, — some 
of the size of a dime. 

Case No. 175, Case Xo. 181, and Case No. 192 (see under 
Haemorrhage) all died of perforation. 

As far as can be learned, in only Case No. 30, who died 
before operation was possible, was any attempt made to op- 
erate. With only temporary hospitals available, with doctors 
and nurses overworked, it is not surprising that operations 
were not attempted. 

Perforation occurred in 2.48 per cent of Osier's 685 cases ; 
in 6.58 per cent of the 4,680 cases tabulated by Fitz. Among 
the 208 Palo Alto cases there were five cases (2.42 per cent) 
of perforation : and all — 100 per cent — were fatal. 

Finney^ gives the percentage of recoveries after operation 
in cases of perforation in typhoid fever as 20.05 P^^ cent. 
Cushing- quotes Keen's figures (Nov. 4, 1899) of a recovery 
rate of 22.7 per cent in 150 cases operated upon. 

Fatal Cases. — Of the 210 cases, 12 died. One of these 
cases — No. 36 (see under Haemorrhage) — died of exophthalmic 
goitre : and another. Case No. 136, died of miliary tuberculosis. 

Case No. 49 did not take to bed until 3d week of illness, 
and the immediate cause of death was reported as pneumonia 
and asthenia complicating the fever. 

In only one case was intestinal haemorrhage reported as 
the immediate cause of death (Case No. 184). 

Case No. 45 was reported by physician as plain, uncom- 
plicated typhoid, with a few specks of blood in stools once, 
and marked delirium and nervousness the most prominent 
symptoms. 

Case No. 30, aet. 14, previous health good. Took to bed 
on 15th day of illness. Symptoms — vomiting, headache, fever, 
pain in bowels, delirium, eruption. Widal reaction positive 
twice. Complications — Relapse and endocarditis. Autopsy 
showed infarction of kidney and brain, degeneration of liver 
and spleen, vegetations on heart valves. 

Case No. 130 (see under Haemorrliagc) had peritonitis. 

1 Finney, J. M. T., Surgical Treatment of Perforating Typlioid Ulcer, Johns Hop- 
kins Hospital, Studies in Typhoid Fever, II, p. 175. 

2 Cushing, Harvey W., p. ?31. 



34 



TYPHOID FEVER AT PALO ALTO, CAL. 



No autopsy and no opinion expressed whether peritonitis was 
due to perforation or not. 

In Case No. 192 (see under Haemorrhage) and Case No. 193 
(see under Perforation) the cause of death was perforation. 



45 



40 



20 



PALO ALTO TYPHOID FEVER EPIDEMIC, 1903 

175 CASES or TYPHOID FEVEK 

70 CASES OF COMPLICATIONS 
26 CASES OF HAEMORRHAGE 
12 CASES OF DEATH 

ARRANGED IN GROUPS ACCORDING TO 

DAY OF TAKIN6T0 BED 

EXPLANATION OF CHART 

Cases of Typhoid Fever Q 

Cases of Complications I 

(including Haemorrhages \ ^ 

and Deaths) ) 
Cases of Haemorrhage 
Deaths ■ 



% 



in 



) Hill 



Day orTAKiMG to Bed (Cc 



JO TROM Day or First Symptoms) 



FIG. 6. 

Complications in RfT.A'i ioN to Day of Illness on which 
'atif«:nts TfX)K to Bed. — iMg. 6 shows the day of illness on 



TYPHOID FEVER AT PALO ALTO, CAL. 



35 



which 175 cases took to bed. The number of cases having 
compHcations in each group is indicated. Under complications 
are incbjded deaths and haemorrhages. 

Eighty-nine of the 175 cases took to bed within the first 
three days. Thirty-two of these cases (36 per cent) had com- 
plications. Ten (11 per cent) of these cases had intestinal 
haemorrhage. It is reasonable to suppose that these represent 
in a general way the cases with most severe infection ; and it is 
not surprising to find a death rate of about 6 per cent. 

Fifty-nine cases went to bed betw^een the 4th and loth day 
of illness, inclusive. These cases represent perhaps a milder 
degree of infection, but they represent also the unfavorable 
condition of activity after the onset of the symptoms. Eigh- 
teen cases (30 per cent) had complications : 10 per cent of this 
group of cases had intestinal haemorrhage: and the death rate 
was 7 per cent. 

Twenty-seven cases may be called strictly ambulatory, 
taking to bed from the loth to the 226. day of illness. Of 
these cases, which m.ay be considered as representing the 
mildest form of infection since they were not ill enough to 
go to bed until so late in the disease — we find 20 cases (74 
per cent.) having complications : eight cases (30 per cent.) 
having intestinal haemorrhage; and the death rate is 11 per 
cent., almost double that of the cases which were severe from 
the beginning but which took to bed early in the disease. 

Secondary Infection, 

In only 2 of the 210 cases reported in the Palo 
Alto epidemic was secondary infection stated as the 
possible cause of the illness. Case 133. — A trained 
nurse caring for typlioid fc^'er patients in a house 
where, previous to her illness, there had developed five cases: 
one on March 5, one on March 20 (another trained nurse), 
one on JMarch 22, one on April 14, and one on April 23. Case 
178. — ^Patient lived in a house in which developed two pre- 
vious cases. That there were several other cases of 
secondary infection seems probable on considering the fol- 
lowing data. The usual incubation varies from 8 to -14 days; 



36 



TYPHOID FEVER AT PALO ALTO, CAL. 



but cases have been recorded with an incubation period of 
23 days/ The sale of the P. milk ceased on April 8, 
and all the milk utensils of the retailer and his customers were 
promptly disinfected. All of the cases up to April 

23 (except as noted on p. 17) are accounted for by direct 
infection if we use the usual 14 days period of incubation. If 
we use the maximum period of incubation — 23 days — all the 
cases up to April 30th are accounted for by direct infection. 
It is reasonable to assume therefore that the 15 cases occurring 
after April 30th w^ere due to secondary infection. That such 
secondary infection is possible is shown by the following 
table: 



Table Showing Possible Sources of Infection in 15 Cases of Typhoid Fever 
Developing in Palo Alto Epidemic too late to be Due to Direct Infection 
from Milk 



Date of First Symptoms 


No. of Cases 


Previous Tases in Same 
House 


Visited Other 
Cases of Fever 




5 


Yes 




6th 


1 


Yes 




" 7th 


I 


Yes 




" loth 




Yes 




" 13th 


I 


Yes 




'■ 20th 


2 


Yes 




" 22d 


I 


Yes 


Yes 


" 23d 


I 


Yes 




" 24th 


I 


Yes 




" 2Sth 


I 


Yes 


Yes 



Although the group of cases between April 23d and April 
30th comes within the possible incubation period, some of these 
cases may have been due to secondary infection, since all but 
two are known to have occurred in houses where tnere had 
been previous cases of typhoid fever. 

Fig. 6 shows graphically the day of taking to bed of 173 
cases ; here may be seen how large a number of ambulatory 
cases there were, each being a possible source of danger of 
secondary infection to the community. Fig. 5 shows the re- 
lation between the time of onset of symptoms and the doctor's 

'•Osier, William: Practice of. Medicine, p. 12. 



TYPHOID FEVER AT PALO ALTO, CAL. 



37 



first visit. It is safe to assume that no sanitary precautions 
were taken until after the physician's first visit. Here again 
may be found ample explanation of some of the later cases. 

PART VL THE SOURCE OF IXFECTIOX OF THE P. MILK. 

(Contributed by WILLIAM FREEMAX SXOW,'- A. M., M. D.) 

In this investigation the writer collected data according to 
the following scheme : 

(1) Data from L., retailer of the P. milk: 

(a) Alphabetical list of customers with dates of beginning and 
discontinuing; 

(b) Numerical list of customers on each of- his three milk routes; 

(c) Charting of the geographical distribution of customers and 
sequence of delivery on each route; 

(d) Concernnig sources of L.'s supplies of extra milk and cream; 

(e) Conditions of handling the milk at L.'s milk depot and on his 
routes. 

(2) Data from L.'s customers: 

(a) Amount of milk taken ; number and time of deliveries ; 

(b) Conditions of caring for the milk; sources of contamination; 

(c) Number of raw milk users in each family ; 

(d) Number of cases of illness pronounced typhoid; number of 

suspected cases, not pronounced typhoid ; 

(e) Popular opinions; notes. 

(3) Data from health officials and physicians: 

(a) Sources of L.'s milk supply; sanitary conditions at producer's 
dairy; possibilitites for contamination of the milk; 

(b) General sanitation information relating to water, sewage, veg- 
etables and other foods of the community; 

(c) Reports of bacteriological and chemical examinations of milk 
and water of the dairies from which L. bought his milk ; 

(d) Reports concerning direct exposure, indirect exposure, and 
possible direct and indirect exposure to infection through 

, the P. milk. 

(4) Data, of varying degrees of trustwortliiness from mis- 

cellaneous sources. 
The mass of information thus collected — largely during the 
epidemic and verified and completed during the two years 
following has been organized with a view of focusing light 
on four main questions: 

(i) Was the P. milk infected on some one of L.'s milk 
routes ? 



^ Associate Professor of Hygiene in Stanford University. 



38 



TYPHOID FEX'ER AT PALO ALTO, CAL. 



(2) Was the P. milk infected at the L. milk depot? 

(3) Was the P. milk infected between the dairy and the 
milk depot? 



ffEDWOOD CITY 
DAIffY 



N. milk rot//Te : no fypho/gf 



8 



No illness; 
sanitary 
conditions, fan 



'ALO ALTO SS 

f5TArirof?D uni- 

LVEf?SITY COM- 
MUniTY 



amar?^ A/s o/s/^o/vers 

Man i wz/fc front Serpa's 
hayc typhoid (one dies) 
Sanitary condition, vile- 

.A 



W. DAIPY 

3 



DEPOT 



\ 



LS occasional 
extra supply. 



No- illness until after Apr i 
Sanitary conditions, fair 



P takes empty cans 



PALO ALTO 
Cf?EAMEf?Y 

No illmss 



Porti/^ese families located on road '\ ,\^'r''~^ 
between 6&7 in yvttich typhoid )■--' 
occurred durim^ first months of 1903]'^ ->q 




SAN FR'AriCISCO 



R 

DAIRY 



F & child ill 
19 niipino mod- choppers 
Sanitary conditions, vile. 



''^'/esj 



SAM 6RE60PI0 

After . . 
return I il 
with 2 

children; aunt, daji^hter Si 

Z Serpa children have typhoid. 



Utef 



Tfuf^ 



Stun 



of'" 



HOUSE 

2 



Cousin from 6.F. 
and Serpa 's wife 6 Z 
childrert c^ie of typhoid. 



FIG. 8.-Infecllon of P. Milk. 

(4) Was the P. milk infected at the P. dairy? 
Fij2:. 8 has been prepared to help make clear the relations 
between the data of this paper. 



TYPHOID FEVER AT PALO ALTO, CAL. 



39 



(i) Was the P. Milk Infected on a Milk Route? 

P. Milk Uniformly Infected. — Definite information has 
been obtained in regard to the 730 users of P. milk who lived 
in homes or boarding houses. Of these, 104 (14 per cent.) 
were on morning deliver}^; 336 (46 per cent.) were on after- 
noon delivery; and 290 (40 per cent.) were on morning-after- 
noon delivery (i. e. delivery twice a day). It is 
estimated after thorough inquiry, that there were board- 
ing at the restaurants which were supplied Avith P. milk, some 
170 milk users; and these are here allotted arbitrarily to the 
three deliveries (A. M., P. ^L, and A. M.-P. II.) in the ratios 
given for the 730 other P. milk users ; giving 14 % of 170 — 24 
restaurant boarders on A. M. delivery, 46% of 170 — 78 on P. 
M. delivery, and 40% of 170 = 68 on A. M.-P. M. delivery. For 
greater clearness these quantities are collected in the following 
Table: 

Table A. — Distribution of the 900 Users of P. Milk According to Deliveries. 





NUMBER OF USERS 


A. M. 

Delivery 


P. M, 

Delivery 


A. M.-P. M. 
Delivery 


In private and boarding houses 
(definitely known) 

In restaurants (estimated) 

Totals 

Per cent, of total (900) 


104 
24 


336 


290 
68 


128 
14% 


414 

46% 


358 
40% 



L. had three milk routes, each of which covered a part of 
Palo Alto and the Stanford University campus (Figs, i, 2 and 
7). On Route No. i there were 415 milk users: on No. 2, 314; 
and on No. 3, 171 : these numbers including the patrons of 
the restaurants which were supplied with P. milk. Total num- 
ber of users is 900. 

The 236 cases of typhoid in this epidemic (not including 
some 40 cases of diagnosed but unreported "walking typhoid") 



40 TYPHOID FEVER AT PALO ALTO, CAL. 

were distributed over the milk routes and deliveries as indi- 
cated in the following Table : 

Table B. — Distribution of 236 Typhoid Cases over Milk Routes and 

Deliveries. 



NUMBER OF CASES OF TYPHOID FEVEE 



Route 


A. M. 


P. M. 


A.M.-P. M. 


All Deliveries 


No. I 


6 


44 


62 


112 




8 


22 


36 


66 




II 


13 


34 


5« 




25 


79 


132 


236 



The relations between the number of cases of typhoid 
and the number of milk users, on routes and on deliveries, 
are clearly shown by combining the foregoing figures in the 
following Table : 



Table C. — Showing Relations Between Milk Users and Typhoid Cases on 
Routes and Deliveries. 





A. M. Delivery 


P. M. Delivery 


A. M.-P. M. 

Delivery 


All Deliveries 




Users 


Cases 


Users 


Cases 


Users 


Cases 


Users 


Cases 


Per Cent 

Cases 
to Users 


Route No. I 




6 




44 




62 


415 


112 


27% 


Route No. 2 




8 




22 




36 


314 


66 


21% 


Route No. 3 




II 




13 




34 


171 


58 


34% 


All routes 


12S 


25 


414 

I 


79 


358 


132 


900 


236 


26% 


Per Cent. Users > 
to Cases S 


iqfr 


19% 


37% 


26% 





Looking at column i and column 10 of Table C, it appears 
that on Route No. i about one fourth of the users had 
typhoid ; on Route No. 2, one fifth of the users had typhoid : 
and on Route No. 3 about one third of the users had typhoid. 
The infection of the milk is thus seen to be quite evenly dis- 



TYPHOID FEVER AT PALO ALTO, CAL. 



41 



tributed over the three milk routes. It will be seen 

from the bottom line of Table C that about one fifth on 
morning deliveries ; about one fifth on afternoon deliveries, 
and two fifths on morning-afternoon deliveries, had typhoid 
fever. The marked increase among the morning-afternoon 
customers may well be due to increased consumption of milk 
by individuals. It has been found that this was a fact in many 
instances. 

P. Milk Continuously Infectious. — It is evident on looking 
at Chart A, Fig. 5, that the whole P. milk supply was continu- 
ously infectious from about March i to April 2. 

(2)' Was the Milk Infected at the L. Milk Depot? 

Conditions at the L. Milk Depot. — Figs, i and 8. L. 
drove the milk wagon on one route and had two assistants 
to drive the wagons on the other two routes. The milk 
depot was in the rear of L.'s house and premises. There 
had been no illness in the L. family nor in the families of his 
two assistants, for a year prior to April, 1903. During the 
epidemic, however, three cases of typhoid fever developed in 
the L. family and four cases in the family of one of the as- 
sistants, — the assistant himself being one of the cases. 

The milk was brought by P. from his dairy to the L. milk 
depot in full three gallon cans. The full cans were imme- 
diately placed in a wooden trough which was then filled with 
water from a tap (town water supply) to within one inch of 
the top of the cans whose lids, except in very warm weather, 
were left on. This trough was emptied and scrubbed once or 
twice a week. For delivery to consumers these cans were 
placed directly on delivery wagons and their contents dis- 
tributed on the milk routes through the use of one gallon 
cans and graduated quart measures. The empty cans were 
returned to the depot from which they were later taken, un- 
washed, by P. to the Palo Alto creamery to be filled 
with skimmed milk; and so returned to the dairy (see Fig. 8). 
All one gallon cans, cream cans and bottles and a few extra 
milk cans were washed and filled at L.'s depot from his other 
minor sources of milk supply. 



42 



TYPHOID FE\'ER AT PALO ALTO, CAL. 



A cesspool situated in the yard of L.'s neighbor, at a 
distance of about 15 feet from the cooling-trough at the milk 
depot, was opened some time in January for the purpose of 
filling. Earth was thrown in until the water in the cesspool 
rose nearly to the surface. The board cover was replaced and 
covered with earth. Later, the cover was removed, and, the 
water having disappeared, the filling of the cesspool was com- 
pleted with earth. The work on the cesspool was done at 
times when there Avas no milk in L.'s cooling trough. 
This cesspool was near the owner's house and directly under 
the window in which the owner's family set their own milk. 

The neighbor's son, who drove on one of L.'s milk 
routes, had a slight illness in the fall of 1902, supposed at 
the time to be due to P. milk which he and his family were 
then using. After this illness this family had its own cow 
and stopped using P. milk. No case of typhoid fever has ever 
occurred at this driver's house, notwithstanding the fact that 
the family, including a number of boarders, contained several 
persons of susceptible age. It seems clear that this 

cesspool could have played no part in the infection of the 
milk ; and mention is made of it only because it has served as 
a popula" explanation of the cause of the epidemic. 

The cream and "special extra" milk which L. supplied to 
his regular cream customers came from a Redwood City dairy 
(Fig. i). Four families in which the etiological factors would 
favor infection developed no cases of typhoid though they 
used this cream until April 8. The bottles and cans used in 
this delivery were washed and handled by L. and his assist- 
ants only. At intervals during Januar}^ and February 
L. got extra milk from the Palo Alto creamery which at thi^ 
time bought milk from the N. dairy (Figs, i and 10). No 
case of illness suggestive of typhoid is known to have occurred 
amon)2^ those persons who used milk from N. or from the 
creamer}' and no other milk. 

(3) Was the P. Milk Infected Between Dairy and Milk Depot? 

(4) Was the P. Milk Infected at the Dairy? 



TYPHOID FEVER AT PALO ALTO, CAL. 



43 



The data bearing on these two questions are given here in 
one group because some of them are common to both. 

Conditions at the Serpa House. — Figs, i and 8. The 
Serpa house was situated on the banks of Madera Creek, three 
miles above Mayfield and one fourth mile below a large dairy. 
The family water supply was drawn directly from this creek 
which was shallow and presented all the usual possibilities of 
contamination by drainage from barns and houses higher up. 
The family consisted of Serpa, his wife and five children. 

The Serpas were visited in December, 1902, by a San 
Francisco cousin. The cousin who complained of feeling ill 
on arrival, after some days took to bed and was nursed by 
Serpa's wife, but had no physician. In a week the cousin 
was up. One week later Serpa's wife became ill and a phy- 
sician being called, pronounced her illness typhoid. The 
cousin again took to his bed ; and the physician diagnosed his 
case also as typhoid fever ; soon two of the children became 
ill with typhoid fever ; and the farmer abandoned what little 
co-operation in medical and sanitary precautions the physician 
up to this time had received from him. 

The San Francisco cousin, Serpa's wife and the two sick 
children died, — the first two after illness complicated with 
haemorrhage. 

There came to the Serpa family during this illness, various 
Portuguese friends to nurse and sympathize ; and these often 
spent the day. (See Fig. 8.) (i) There came a man 

and his wife who were subsequently ill with typhoid fever 
'at the N. dairy (see p. 47). (2) There came the P. 

family of the P. dairy. (3) There came an aunt and 

her daughter (aunt and cousin of Mrs. Serpa) from San 
Gregorio (a seacoast town, 40 miles away). After the 
deaths, the aunt and her daughter, taking two of the Serpa 
children, returned to San Gregorio, where all four developed 
cases of typhoid. Also in the aunt's family there occurred a 
case of typhoid in a member who had remained in San 
Gregorio. (4) There came a Portuguese family living 

on the Los Trancos creek (Figs, i and 8) on the road from 



44 



TYPHOID FE\"ER AT PALO ALTO, CAL. 



the P. dairy to Palo Alto ; and in this family and three near-by 
Portuguese families there developed between December, 1902, 
and February, 1903, five cases of typhoid fever. 

Conditions at P. Dairy. — A part of the sanitary conditions 
at the P. dairy have been described in detail (p. 52). The 
following additional facts which have a bearing on milk in- 
fection are given here. 

There is evidence to show that the P. milk was at times 
diluted with water before delivery to the L. milk depot (see 
Appendix E). 

The P. creek above spring ''B'' (see Figs, i, 3 and 9) is 
dry during summer and rainless periods in winter. The 
products of the privy and pig pen, just above the spring, would 
therefore accumulate during dry spells, and be swept down 
over the spring to the dam, by each heavy rain. 

The family (including five children") of the owner of the 
ranch on which the P. dairy was located, took milk regularly 
from the dairy. Two neighboring families, containing young 
people and children, drank the P. milk during the winter; 
and after the sale of this milk was stopped in April, continued 
to use the milk in all forms in increased amounts until the 
cows were dried up or sold. One of these families received 
its supply regularly in private utensils placed under the P. 
"cooler :'" the others are said to have received their sup- 
plies from the general dairy cans. This is of interest in re- 
lation to the alleged watering of P. milk. With the 
exception noted below the water used by these families came 
from individual springs. One family was compelled during 
the rainy season, by the inaccessibility of their spring, to use 
water taken from the creek, only a few hundred feet below 
the P. dairy. Among the 30 persons thus exposed 
at the dairy no case of illness suggestive of typhoid fever is 
known to have occurred. 

The water which supplied the P. milk house also supplied 
the county tanks used in watering the roads. These tanks are 
distributed over a distance of several miles down the creek 
and some of them are supplied with drinking taps. Teamsters 



TYPHOID FE\'ER AT PALO ALTO, CAL. 



45 



and travelers regularly drank at these places, but it is not 
known whether or not any case of typhoid occurred among 
these drinkers. 

P. lived on the bank of the creek a few hundred feet above 




FIG. 3.— P. Dairy Drainage Area. 



the intake of the dairy water system, in "House No. i" (Fig. 
3 and Appendix C). There were no buildings higher up on 
the drainage area of this stream. P.'s child, approximately two 
years old, is known to have liad during January, 1903, a con- 



4^ 



TYPHOID FE\ER AT PALO ALTO, CAL. 



tinuous fever extending without crisis over a period of three 
weeks with temperature ranging between ioo° and 104°. Clin- 
ical examinations suggested pneumonia and the attending phy- 
sician who was called late in the case so diagnosed the case. 
Notes were not kq:»L and the recovery occurred without fur- 
ther facts. P. also is known to have been in ill health 
during January and February. He was not under the care of 
a ph^'sician, but complained to his friends of ill health and 
general malaise. Whether his was a case of ''walking typhoid" 
is merely conjecture. No other member of the family was ill' 
The P. family is known to have visited the Serpas (see 
p. 43 and Fig. 3) while the latter were ill of typhoid fever; 
and to have attended the funeral of one of the household who 
died of typhoid. 

During the winter of 1902-3 nineteen Filipino wood chop- 
pers and a number of lumbermen were employed in the hills 
surrounding the P. dairy ; they were frequent visitors to the 
dairy ranch as they were in the employ of its owner. AV^ell 
marked areas of primitive out-house facilities were found on 
the bank of the P. creek near the pig pen (Figs, i and 9) just 
above the dairy water supply intake. 1 he possibil- 

ity of chronic intestinal diseases among the nineteen Filipinos 
is suggested in relation to the fact that there was an unusually 
large number of haemorrhage cases in the Palo Alto epidemic, 
and diagnoses in several instances of "para typhoid." 

Conditions at the N. Dairy. — The main features of the N. 
dairy are shown in Appendix D. Further conditions which 
have a possible bearing on the cause of the infection of the P. 
milk, are stated here (see Figs, i and 8). 

In August and September, 1902, L. (milkman of Palo Alto) 
was buying milk of the N. dairy. There was at this time some 
illness with ^iastro-intestinal symj^toms among those to whom 
this milk was sold. In September L. sued N. for damages 
on the ground that N.'s milk was bad ; and obtained judgment. 
L. at once stopped buying milk from N. 

During the winter and up to April 8, N. was selling milk 
to the Palo Alto creamery — 40 gallons a day. He had also a 



TYPHOID FEVER AT PALO ALTO, CAL. 



47 



small number of regular private customers in Palo Alto during 
the same period. No case of typhoid fever appeared among 
his private customers or among the customers of the Palo 
Alto creamery, v^hich retailed his milk. 

In January, 1903, a man and his wife came to the N. 
house from the Serpa house where they had attended typhoid 
fever patients (see p. 43). The man and his wife both fell 
ill of typhoid fever, and the man died. 

On April 8, 1903, as a result of their inspection of the N. 
Dairy the Palo Alto Board of Health ordered N. to stop 
selling milk in Palo Alto. On April 18, N. was arrested and 
fined $20.00 for attempting to sell milk in Palo Alto contrary 
to order. On May 7, N. was fined $75.00 for keeping an 
unclean dairy, contrary to ordinance of Santa Clara county. 

The samples of milk and water taken at the N. dairy by 
the Palo Alto Board of Health on April 7 (see p. 53), were 
sent to the county health officer, whose bacteriologist re- 
ported that the samples contained typhoid bacilli. 

Conditions at the Creamery. — During a portion of the 
winter and up to April 8, 1903, the Palo Alto creamery bought 
about 40 gallons of milk daily of the N. dairy ; and additional 
milk of various other dairies. The creamery made 

butter, and retailed milk and cream over the counter and had 
besides a milk route. The creamery occasionally sold cream 
and milk to L. when his customers needed extra supplies. 

The creamery, for some months prior to April 8, 
was selling separated N. milk to P. who brought his 
empty cans from the L. depot to have them filled. So far as is 
known, the P. milk wagon stopped at no point other than the 
Palo Alto creamery, between the dairy and the milk depot. 

There was no case of typhoid fever reported among those 
who used creamery milk and cream only. 

Recapitulation and Conclusion. 

Recapitula'lton. — The chief data bearing on each of our 
four questions are here arranged in two groups according as 
they count for or against a positive answer to the question. 



48 



TYPHOID FEVER 



AT PALO ALTO, CAL. 



Question (i) : Did the infection of the P. milk occur on 
one of L.'s milk routes? For: The first case recorded in the 
epidemic may not have been due to P. milk, but on the con- 
trary, may itself have been the cause of the infection of that 
milk, through the agency of the driver of the milk wagon 
and the utensils of the infected household. Against : (a) The 
first few cases of typhoid in the epidemic were scattered over 
all three milk routes, — not confined chiefly to that one on 
which the first case occurred, as we should expect it to be if 
the infection of the milk were due to the first case of typhoid', 
(b) The infection of the whole P. milk supply was continuous 
over a period exceeding one month, which is contrary to what 
we should expect if the first case of the epidemic infected the 
milk on one of the routes. 

Question (2) : Did the infection of the P. milk occur at 
the L. milk depot ? For : Occasionally L. got extra milk from 
the Palo Alto creamer}^, which got milk from the N. dairy 
(see Fig. 8), where occurred two cases of typhoid fever. 
Against : But no case of typhoid fever occurred among those 
who used exclusively either N. milk or creamery milk. 

Question (3) : Was the P. milk infected between the dairy 
and the depot? For: There was typhoid fever in four Portu- 
guese homes located on the road over which the P. milk passed 
on its way from the dairy to the depot. Against: (a) It can- 
not be learned that the milk wagon ever stopped at one of 
these afflicted homes, or even that the driver of the wagon was 
acquainted witli any of these four families, (b) The milk was 
continuously infectious for one month. 

Question (4) : Was the P. milk infected at the P. dairy? 
For: (a) There were two cases of typhoid fever at the N. dairy; 
N. delivered milk daily to the Palo Alto creamery and it was 
I'^.'s custom to take home from the creamery in the empty cans 
])icked up at the L. milk depot, the separated N. milk, (b) 
P.'s family visited the Serpa family at the time of the typhoid 
fever at tlic house of the latter; and attended at the same 
house the funeral of one of those who died there of typhoid. 
P. and child were ill later with symptoms resembling in some 



TYPHOID FEVER AT PALO ALTO, CAL. 



49 



degree those of typhoid. The P. privy stood on the bank of 
the creek (Figs, i and 3). The rains of late January and 
early February, of March and early April (Chart C, Fig. 5) 
carried down to the dam the privy deposits accumulating 
between rains. The privy deposits on arrival at the dam were 
dropped by the slackened current, and remained to contin- 
uously contaminate the impounded water, which was daily 
drawn upon for use in the milk house, and at times for diluting 
the milk forwarded to L. This milk was for a month con- 
tinuously infected with the germs of typhoid fever. Against 
(a) : Among the customers of N. and the creamery who used 
no other than N. or creamery milk, there was no case of 
typhoid. Against (b) : Nothing. 

Conclusion. — The continuous infection of the P. milk 
supply required a continual contact with a continuing source 
of infection, and this in view of all the known facts forces us 
either to look upon the P. cans as continuously infected by N. 
milk or to regard the creek water used in the P. milk house 
as continuously infected. We are barred from considering the 
P. cans as infected by the N. milk by the fact that no one who 
used N. milk or creamery milk only, had typhoid fever. Thus 
w^e are finally brought, both b}^ this process of elimination and 
by the sequence of events connecting the typhoid at the Serpa 
house with the P. illness, the privy on the bank of the creek, 
the rains and the impounded water at the dam, to the conclu- 
sion that the P. milk was infected through admixture with 
the creek water used at the milk house of the P. dairv. 



50 



TYPHOID FEVER AT PALO ALTO, CAL. 



PART VII. APPENDICES. 

Appendix A. 

(From the minutes of the meetings of the Palo Alto Board of Health.) 

Oct. 6, 1902. — "Resolved, That this Board recommend to the Board of 
Trustees that the office of Inspector of Milk in and for the Town of 
Palo Alto be hereby created ; his duties to be the inspection of all milk 
sold or delivered in this town and the maintenance of such milk up to 
the standard to be fixed by committee for that purpose at this meeting; 
other details of his duties to be fixed by same committee. On motion 
the Chairman and Health Officer were appointed as such committee." 

Nov. 3, 1902. — "On motion of Dr. Moss, the Secretary was ordered 
to communicate with the Board of Town Trustees inquiring of the Board 
as to what action was taken by that Board in relation to the appointing a 
milk inspector for this town." Dec. i, 1902. — "It having been re- 

ported that no action by the Board of Town Trustees had been taken in re- 
gard to appointing a milk inspector for this town, on motion it was ordered 
that the Secretary be instructed to communicate with Town Trustees, in- 
quiring of them as to when they would be ready to entertain the question of 
appointing a milk inspector for the Town of Palo Alto." Jan. 5, 

1903- — "The Secretary reported that he had received no communication 
from the Town Board of Trustees in answer to his letter of inquiry about 
appointing milk inspector." 



TYPHOID FEVER AT PALO ALTO, CAL. 



51 



Appendix B. 

Please fill out AT ONCE, and as fully as possible, this Typhoid Fever blank, and 
without waiting to gather further data, kindly send it to 

BOARD OF HEALTH, Palo Alto. 

Records of Board of Health of the Town of Palo Alto, California 

TYPHOID FEVER 

No Name of patient 

Street and No. when taken ill 

Present address 

Records of Board of Health of the Town of Palo Alto, California 
TYPHOID FEVER 

(The name and address of patient will be torn from the remainder of this sheet immedi- 
ately on return to the Board.) 

No 

r of first symptoms 19 

Date \ of taking to bed 19 

( of physician's first visit 19 

Age sex c-.lor nationality 

Place of work, business or school 

Physician while ill , 

Health before attack 

Out of town (date) • 

Patient discharged by physician (daie) 

{ Chills Pain in Bowels Tongue 

i. ) Vomiting Nosebleed Delirium 

symptoms -< headache Diarrhoea or Eruption 

( Fever Constipation Spleen 

Widal reaction: Made? Date when ) Date when ) Date when \ 

[Ves or No) Positive ) ' ' 'Sugg'stive \ ' ' ' Negative j" ' ' " 
Complications 



Drinking Water \ IZlflfy Milkman 



Milk delivered 



Source of cream and 
extra milk supply 



Private well 

A. M 

. P. M 

Previous cases in the house 

Has patient visited other cases? 

Privy or Water Closets Plumbing 

What probable sources of infection 

What possible sources of infection 

Remarks 



(Signature) 



M. D. 



52 



TYPHOID FE\ ER AT PALO ALTO, CAL. 



Appendix C. 



Record of Dairy Inspection. 



Board of Health of Palo Alto, Calif. 



April i, 1903. 



Dairyman: J. E. P. (bought out P. F., Jul}^ i, 1902.) 
]\Iilk delivered in cans to E. L. 

Stable : Fairl}^ lighted and ventilated. Wooden floor cleaned with 
shovel. Cobwebs and dust present. Not lime-washed. 

Water supply : During wet weather stock, is watered with water from 
spring "A" ^ back of barn. During dry spells .water is taken from sump 
at dam below spring "B," which is in bottom of creek. Spring "A" is 20 
feet higher than stable, and on a hillside ; but little protection against 
surface water, from cow trail on upper side of spring, running into spring. 
Spring '"B" rises in bottom of creek, and is not protected in any way. 



Water is diverted by dam into box or sump, from which it is pumped to 
stalls and dairy house. Pig pen contains three pigs and is in bad con- 
dition; and all refuse slides down the bank to. the creek bed 10 feet dis- 
tant. 

Privy on bank opposite the upper house. 

Utensils are washed in dairy house. Water supply same as for water- 
ing cows 

Cows said to have been examined in September, 1902, at request of 
owner by Dr. B — — , and reported healthy. Cows running on ^rolling 
pasture. Feed bran, millings and oilcake when feed is short. 

The four milkers are: J. K. I'., j. P., J. C. and C. L. Said to be no 
sickness among dairy hands or family. 

Inspection made l^y the president and secretary of the Palo 
Alto Bo ard of Health. 

1 See Figs. 3 and 9. 




. Dairy 

Apr. !, 1903. 



FIG. 9. 



TYPHOID FEVER AT PALO ALTO, CAL. 



53 



Appendix D. 



Record of Dairy Inspection. 
Board of Health of Palo Alto, Calif. 



April 7, 1903. 

N. Dairy: On Bay side of Mayfield. 

Supplies 56 gallons daily to Palo Alto Creamery. 

Dr. ]\Ioyer (health officer of ^layfield) says two (2) cases and one 
death of typhoid fever at this place two months ago. 

Sample of milk taken from can which was waiting to be taken to Palo 
Alto. Sample of water taken from faucet. 

N. says an inspection of his cattle was made by county two years ago. 

Everything in milking barn covered with cobwebs several inches thick. 



N. 



Apr. 7/03. 



Ca If Yard 
r- — -*S House 



, Lo.U_J 

Ca/f f-rou^n from Faucet- to \ J 

^.it^ ^ Coo/en 



manure h eapC3\a^ / 
Wint/mi// pump/ty /h/b //J'/r/f fnorr? >v<// 
ir>/htc/7 /V. says /s fiF/^Cf-r 







Pond of 
S/a^nanf 

Surroi/ndihcj 



Past-L/re 



cans fff 
/n/Z/c are set 
/o keep coo/. 



-Sfoch-frou^h 

&CKm Yen r-d 
slopes eJoy^n ^ard fo north c/rrcZ/S 
deep Y^i-f/} tyiud frrttrfLfre . 



FIG. 10. 



Milk house floor covered with slime of milk and water (from cooler) 
and litter of straw and manure carried in from milking barn on boots of 
milkers. Milkhouse walls covered with cobwebs. 

All water said to be supplied from well marked on diagram,^ page 2 
hereof. 



1 See Fig. 10. 



54 



TYPHOID FEVER AT PALO ALTO, CAL. 



Can washing is done in a shanty where are stored vegetables and va- 
rious odds and ends, — a filthy place, the floor being littered with manure 
brought in on boots. Water is carried in pails from faucet at trough near 
wash house and heated in three (3) old milk cans. Dried cans were in- 
spected and found to be covered on the inside of mouth with a thin film 
of dried dirty water containing cowhair and particles of manure mixed 
with straw. 



Inspected by the president and secretary of the P. A. Board 
of Health. 



TYPHOID FEVER AT PALO ALTO, CAL. 



55 



Appendix E. 

L/s Contract With the Dairyman. — The following is an 
extract from the contract between E. L. and P. F., made on 
November 21, 1900. * * It is is also further agreed 

that said milk delivered by the party of the first part to the 
said party of the second part shall contain not less than 3 1-5 
per cent, butter fat and to have an average of 3 4-5 per cent, 
butter fat." P. F.'s part of this contract was assumed by J. 
E. P. on July i, 1902. 

L. s Record of Milk Testing. — (Written at time of the 
tests by Mrs. L.) Oct. 22, 1902: We tested milk that was 
brought Oct. 22 in morning and found water ; also that 
brought on night of Oct. 22, we tested and found water. 

The milk brought on the morning of Oct 22 was 
tested in the presence of the following witnesses, and water 
was found: P. P., Mrs. M., Mrs. K., J. T., Mrs. E. L., E. L. 
We tested 8 cans out of 24 taken from different parts of the 
trough. W e tested the milk brought at night of Oct. 

23, and there was water, but not much. The milk 

brought on the morning of Oct. 24 was tested in the presence 
of the following witnesses and water was found : Mr. M., 
Mrs. J. T., Mrs. B., E. L., Mrs. L., and the driver that brought 
the milk. The milk brought at night of Oct. 24 was 

tested and no water was found. 

L.'s Statement of March 28, 1905. — I had no fault to 
find with milk and cream supplied by P. P., except that he 
did not give me the quantity and did not cool properly. 
After P. took charge of the dairy I found the milk and cream 
short in butter-fat. On Oct. 22 T tested the milk and found 
water, and threatened them then to quit and not pay them 
if T caught them watering the milk again. The amount which 
they delivered to me at once dropped to 15 gallons less than 
they had been bringing. Later I made frecpient tests but did 
not find any water so far as the tests would indicate. A very 
small amount of water could be jnit in and the tester would 
not show it. T was always after them when anything was 
wrong. 



56 



TYPHOID FEVER AT PALO ALTO, CAL. 



Appendix F.^ 

(i) In one of the January cases of typhoid fever the patient 
was a young man who had been away from home for several 
months continuously previous to his illness. He left his 
work at a distant point to return home ill. (2) The 

patient lived with his family just outside of Palo Alto but 
worked in an office in San Francisco. He lunched at various 
San Francisco restaurants and returned home each evening. 
His case presents a negative history so far as P. Milk is con- 
cerned. His father died in 1896 of typhoid fever at the same 
home. The popular belief that the patient became infected 
while cleaning a house drain at his home some six months be- 
fore becoming ill, is not the probable explanation. The 
patient's illness and death occurred at the height of the epi- 
demic. (3) In March, 1903, a Japanese janitor in the 
men's dormitory on the Stanford University campus died sud- 
denly. An autopsy revealed typical typhoid lesions, enlarged 
spleen, and general lobar pneumonia. There was no apparent 
perforation though the ulcers were numerous and deep with 
evidence of slight haemorrhage. The brain showed no evi- 
dence of injury. This man frequently took walking trips in the 
hills and within one month of death was known to have spent 
a day along the stream below the Serpa house (see p. 43 
and Fig. i) in which four deaths from typhoid had recently 
occurred. He was in the habit of taking whiskey and a cup, 
but whether he drank milk or water on this trip is not known. 
This man was one of twelve Japanese janitors living in the 
basement of this dormitory, who boarded themselves and 
were not using P. milk. The eleven other janitors were not ill 
at any time during the epidemic. (4) A Japanese 
student working for a Palo Alto family in which the milk used 
was from the family cow, obtained previous to his illness 
leave to go to College Terrace (Fig. i) to nurse a sick friend. 
Who the sick friend was cannot be determined. The absence 
of the Japanese student continued for two weeks, and on his 
return to his employer he was evidently not well. A physician 
was called. After a short illness the patient died in the hos- 
pital. Autopsy showed typical typhoid lesions. Death re- 
sulted from perforation. 

^ Contributed by Dr. Snow. 



TYPHOID FEVER AT PALO ALTO, CAL. 



57 



Appendix G.^ 

(i) Six family groups representing altogether 25 to 30 
persons used milk from the P. dairy but had no case of typhoid 
fever. It is known, however, that these six families boiled 
their milk before using it, during the entire winter. 
(2) In a group of 24 families using P. milk no typhoid oc- 
curred. But of these persons all were above the age of 35 
years and therefore comparatively immune. (3) Four 

families who took cream of L. (retailer of P. milk) had no 
illness. However this was not P. cream, but came from the 
Redwood city dairy (see p. 42 and Figs, i and 8) in bottles 
washed at the L. milk depot. 



^ Contributed by Dr. Snow. 



TYPHOID FE\-ER AT PALO ALTO, CAL. 



Appendix H. 

The Reorgaxizatiox of the P. Dairy. — At the time of the 
first inspection of his dairy P. stated that the creek water 
was pumped into the two large horse troughs which stood just 
belovr in the barn yard, and was piped from these by gravity 
to the milk house (Figs. 3 and 9) : and the visible portions of 
the piping corroborated this statement. It was also under- 
stood from P. that a pipe line ran directly from the hill- 
side spring to the milk house. However, on a second inspec- 
tion, April 8, a storage tank (with a capacity of perhaps 500 
gallons) was discovered in one of the stables where it was 
concealed by rough partitions : and further search revealed the 
fact that the tank was directly connected with the pump at 
the dam, the hillside spring, and the milk house, by three sep- 
arate pipe lines. It w^as now plain that this tank served at 
times as a storage reservoir for the creek water, and at all 
times for the spring water. It thus appeared that the hillside 
spring water had been, from the 2d to the 8th of x-\pril, pass- 
ing through a reservoir and some 200 feet of piping through 
which creek water had passed at some uncertain previous 
earlier date. 

Was the spring water between April 2d and 8th contami- 
nated by this passage? 

If we take 23 days as the maximum period of incubation 
(see p. 36), all cases of typhoid fever developing up to April 
25th (see Chart A, Fig. 5) are accounted for as being in- 
fected previous to April 2d. All but one of the 18 cases which 
developed after April 25th may be accounted for as being due 
to secondary infection (see p. 35). Using this 23-day in- 
cubation period leaves all the cases accounted for without 
assuming that the spring water was contaminated between 
April 2d and 8th. As, however, the 23-day period of incuba- 
tion is abnormally long, we are not justified in concluding that 
the spring water was not infected in its passage through the 
tank. 

This incident brings to mind the fact that in Ithaca, N. Y., 
after shutting off from the city mains the water which caused 
the typhoid epidemic, the authorities turned on the new supply 
of water without disinfecting these mains. 



TYPHOID FEVER AT PALO ALTO, CAL. 



59 



Appendix I. 

Sanitary Science; Physicians and the People. — It is 
the popular belief that the training of a physician includes an 
extended study of sanitary science and its application to public 
health ; as witness the fact that nearly all state and municipal 
boards of health in this country are made up entirely of phy- 
sicians. The truth is, most medical schools do not include in 
their curricula a course in sanitary science ; and a physician 
who through inclination or by reason of holding a position as 
health official, desires to thoroughly post himself in sanitary 
science must do so by private study. It is the part of the 
physician to cope with the contagious disease germ while it 
is resident in the human body; it is the business of the sani- 
tarian to prevent the germ.s entering the human body. 

Histories of epidemics and accounts of what has been done 
by those who have had experience in sanitation work in this 
country are to be found in reports of boards of health of states 
and cities ; but the gist of the matter is presented by Professor 
Sedgwick in "Principles of Sanitary Science and Public 
Health." A health official, whether physician or not, who is 
not familiar with the principles set forth in this book is by 
reason of the authority given him by law, a source of special 
danger to the public health. On the other hand, every person, 
whether physician or not, who has taken the trouble (which 
amounts to little) to inform himself on these principles, not 
only knows how to protect himself against contagious disease, 
but serves to prevent the spread of contagious disease as a 
fire-proof building serves to check a conflagration. 

Concerning Quarantine. — Most persons who consider san- 
itary matters at all, have the notion that health officials alone 
are responsible for the prevention of the spread of contagious 
disease. A little thought will show that the quarantine of a 
case of contagious disease depends for its efifectiveness on the 
full co-operation of three parties : the health officials, the at- 
tending physician, and the persons quarantined. The health 
officials are responsible for the wisdom of the quarantine rules 
and regulations, but can be properly held responsible for their 



6o 



TYPHOID FEVER AT PALO ALTO, CAL. 



rigid enforcement only when the public is willing to pay for 
sufficient special police to guard the quarantine lines night 
and day. The public seems to be willing to go to this expense 
only in the case of smallpox or plague. Where the public 
does not consent to the use of such special police, the health 
officers cannot prevent the breaking of quarantine rules, — 
the most they can do is to bring the offenders into court for 
misdemeanor. If the offenders demand a jury trial they may 
be convicted if the public is alarmed, but otherwise are likely 
to go free. The attending physician must help the persons 
quarantined to understand the rules, and accept every oppor- 
tunity to encourage them to conduct themselves in accord- 
ance with the spirit as Avell as the letter of those rules. The 
persons quarantined must follow the rules to the best of 
their understanding ; and this they will be able to do the more 
cheerfully if they regard the rules from time to time from 
the point of view of their neighbors just over the quarantine 
line. Too often we hear a family cry out against the danger- 
ous laxity of quarantine restrictions at a neighbor's house 
and then stoutly oppose the same restrictions as unreasonable 
when applied to themselves under the same conditions. 

Frequently a family brings pressure to bear to cause 
the attending physician to help them break the spirit or the 
letter of the quarantine rules. Too frequently the physician 
gives way more or less to this pressure ; for the hardships of 
quarantine are actual and present, while the harm which may 
come from laxity in quarantine is problematical and in the 
future. 

The need of special quarantine police is becoming less and 
less because (i) physicians are giving more attention to 
preventive measures; (2) the employment of trained nurses 
is increasing ; and (3) through the medium of the physician 
and the trained nurse the people are by precept and example 
coming to understand and appreciate the value of preventive 
measures. 

The conduct of a conscientious, intelligent and well trained 
nurse in the care of a patient in quarantine is an object lesson 



TYPHOID FEVER AT PALO ALTO, CAL. 



6t 



whose value is limited only by the intelligence of the patient's 
family. The indirect value of the presence of a nurse may thus 
in the long run be far greater than the direct. 

Those persons who take no middle ground between in- 
difference to sanitary precaution and a state of panic are the 
greatest source of danger to the public health. 

Supervision of Milk Supply. — In many cities and towns 
the inspection of milk supplies consists in making tests to de- 
termine if the milk has been robbed of part of its cream, or if 
water has been added. This testing for water and skimmed 
milk furnishes a protection to the pocket rather than to the 
health of the consumer. The fact that such testing furnishes 
no protection to the consumer against disease-infected milk is 
emphasized in this epidemic. L., the retailer of the P. milk, 
v/as making his utmost effort during the few months imme- 
diately preceding the epidemic, to insure his customers good 
milk ; and to this end made frequent use of a lactometer and a 
Babcock tester in testing the milk as it came to him from the 
P. dairy. (See Appendix E.) 

In some municipalities the board of health exercises de- 
tailed supervision over the dairies within the corporate limits. 
In a small number of places the board of health exercises this 
supervision over the dairies which lie without as well as over 
those which lie within the mimicipality. Health officials of a 
municipalit}' haA'e no authority to inspect the outside dairies 
except such authority as the owners may give. But' authority 
from the owners is immediately forthcoming if the board of 
health bars the entrance of milk which comes from outside 
dairies which have not been approved by the board. Palo 
Alto has found it eas}' during the pa.st two years to give the 
outside and inside dairies uniform treatment — the outside and 
inside dairymen showing equal desire to make their milk- 
cleaner and l)etter. 

Experience shows that supervision of milk su]:)ply should 
begin with the inspection of water su])])l}' at dairies, and as 
soon as practicable follow with inspection of dairy herds, ar- 
rangements and methods. Tests for butter fat. total solids. 



62 



TYI»HOID FEVER AT PALO ALTO, CAL. 



and preservatives and bacteriological examinations should come 
last, unless the complete supervision can be undertaken. By 
those who are familiar with the routine of dairy work and the 
channels through which contagious disease germs may be 
transmitted from person to person, this conclusion may be 
reached by reasoning a priori. Unfortunately no member of 
the Board of Health felt qualified before the epidemic to pass 
judgment on dairy methods, and it seemed under the circum- 
stances the most business-like procedure to inaugurate the 
supervision of the milk supply under the guidance of an ex- 
pert in dairying. From the experience of the Palo Alto Board 
however, it is plain that boards of health should not delay 
dairy inspection until a thoroughly competent inspector can 
be secured but forthwith direct those of its members who know 
the fundamentals of sanitation to make the inspections. These 
amateur inspections if conscientiously made will hardly fail to 
discover the more dangerous conditions. 

To secure satisfactory progress in dairy improvement 
boards of health must be on the watch not only to condemn 
what is dangerous but to show the dairymen where and how 
to make improvements in arrangements and methods. So 
long as the mass of the people fail to appreciate the efforts of 
the dairymen to produce cleaner milk, it will be difficult to 
get the dairymen to make such efforts. Dairymen cannot be 
expected to go to additional expense to make their milk 
cleaner so long as the majority of people carry their investiga- 
tion of a milk supply only to the point of ascertaining the 
price per quart. 



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